PROCEEDINGS

of the
XXXV National Continuing
Medical Education Programme
In Surgery

SURGERY UPDATE 2017

Compiled by:

Dr. Pawan Lal

MBBS, MS, DNB, FIAS, MNAMS, FICS, FIAGES, FIMSA, DA

Prof. Rajdeep Singh

MBBS, MS

Department of Surgery
Maulana Azad Medical College
associated
Lok Nayak Hospital
New Delhi
Year of publication: 2017

Price of extra copy of Proceedings: Rs.750/-

NOTE: The Organizing Committee of SURGERY UPDATE 2017 takes no

responsibility for the contents of the lectures which are the sole
responsibility of the concerned authors. None of the lectures has been
edited in part or in whole. A part or whole of the lecture may be reproduced
with the prior permission of the concerned author.
 FOREWORD
The National Continuing Medical Education Programme in Surgery organized by the
department of Surgery, Maulana Azad Medical College, New Delhi is in its twenty
ninth year of existence. During this period has blossomed into a six day academic
exercise eagerly looked forward to by the surgeons all over the country and has
established itself as the gold standard for Continuing Medical Education
Programmes. One of its endearing features is the CME lectures brought out in a
bound format simply named the PROCEEDINGS, introduced and published in 1998
The PROCEEDINGS have become an integral part of the update since then. It is
satisfying to note that the bound lectures are carried by postgraduates all over the
country preparing for examinations or for interviews. Those who miss out on
attending the CME programme, still manage to procure copies of the
PROCEEDINGS in its photocopied form. This year also it gives us great pleasure to
present a book on the PROCEEDINGS OF THE XXXV NATIONAL CONTINUING
MEDICAL EDUCATION PROGRAMME IN SURGERY, similar to previous years.

Every surgical disorder in the scientific programme has been chosen carefully in the
context of its importance to the attending delegates. All the authors are well-
recognized authorities with a vast personal clinical experience on the particular
subject they were chosen to elaborate. As will be evident from the written texts, they
have contributed a very comprehensive account of the respective topics and are also
to be commended for submitting the latest references at the end of each chapter for
ready referral. The quality of their text reflects their involvement in our programme. A
sincere effort has been made to format the book in a uniform manner without any
effort to edit the text provided by the contributors.

This year’s programme is a full day comprehensive CME on selected topics of

particular interest to the postgraduate. Emphasis is on subjects with more bearing on
their clinical application. Every year’s Proceedings can be considered one part of the
trilogy of books which will cover nearly the whole course for the postgraduate student
over a three year period.

We sincerely thank the contributors for their effort. We also wish to thank all the
colleagues in the department for their encouragement and guidance in making this
project possible. Especial thanks are to Prof. Rajdeep Singh, who has been
instrumental in collecting the articles and majorly formatting the text to its final form.
Our sincere thanks are also due to the resident staff who worked for procuring, proof
reading and formatting the text. Finally, we must emphasize the contribution of the
authors who have always given an overwhelming response to our endeavor of
bringing out the written text of our CME programme over the years. We sincerely
hope that the Proceedings will meet the stiff demands of the delegates and serve as
a nodal point of learning for the postgraduates.

Dir. Prof. Sanjeev Kumar Tudu Dr. Pawan Lal

HOD, Surgery, MAMC & LN Hospital Organizing Secretary
& Organizing Chairman SURGERY UPDATE 2017
SURGERY UPDATE 2017
 CONTRIBUTORS

Malrotation of gut Tracheo-oesophageal fistula

Dr Shandip Sinha Dr SK Aggarwal
Professor Paediatric Surgery, MAMC MS, MCh (AIIMS), Senior Consultant
Paediatric Surgeon, Sir Ganga Ram
Hospital, New Delhi

Undescended testes Current classification and staging

Dr Raman Kataria of breast cancer
Secretary, Jan Swasthya Sahyog NGO Dr. Anurag Srivastav
actively working in Chattisgarh. Member, Professor and Head, Department of Surgery
Sector Innovation Council, NHSRC, India; AIIMS
Member, CAPART, Ministry of Rural
Development, Govt of India

Management of a patient with Management of a patient with locally

early breast cancer advanced breast cancer
Dr P. N. Agarwal Dr K Geeta
Ex HOD, Director Professor, Department of Associate Director and Head, Breast Services
Surgery, MAMC (Surgical Oncology)
Max Cancer Centre, Max Healthcare,
Patparganj, Delhi

Management of a case with Sentinel L N. biopsy

metastatic breast cancer Dr Ishan Mohan
Dr Kum Kum Singh Consultant in Department of Surgical
Retd Senior Professor And Head Of Deptt Oncology, Action
Surgery Cancer Hospital, Delhi
J.L.N.Medical College , Ajmer (Rajasthan)

Mastectomy Axillary dissection

Dr Rajdeep Singh Dr Anurag Mishra
Professor, Department of Surgery, MAMC Associate Professor, Department of
Surgery, MAMC

Breast reconstruction Ca tongue

Dr. Raghav Mantri Dr Nitin Leekha
Principal Consultant, Max Institute of Consultant Surgical Oncology,
Aesthetic & Reconstructive Plastic Jaypee Hospital, NCR
Surgery.

Achalasia cardia Hyperparathyroidism

Dr Lalit Aggarwal Dr Vivek Aggarwal
Professor Surgery, Lhmc & Dr RML Consultant and Head Division of Endocrine
Hospital and Breast Surgery, Diabetic Foot Unit
B L K Super Specialty Hospital, Director
Centre for Thyroid, Breast and
Endocrine Disorders, New Delhi, India

Chest trauma Premalignant conditions of

Dr. Subodh Kumar colon Dr Deepak Ghuliani
Professor Surgery , AIIMS, Delhi Professor, Dept of surgery, MAMC
Investigations and Staging of
colorectal cancer
Dr. Ashish Jakhetiya
Assistant Professor, Cancer surgery,
VMMC and Safdarjung hospital
Surgical options for colorectal
cancer Dr PK Mishra
Consultant GI Surgery, Max Hospital, Delhi
Ileostomy / colostomy
Dr Nikhil Gupta
Associate Professor ,Department of
Surgery
Dr RML Hospital and PGIMER Delhi
Thyroidectomy
Dr. Vivek Agarwal
MS, M.Ch (Endocrine Surgery)SGPGI
Consultant and Head Division of Endocrine
and Breast Surgery, Diabetic Foot Unit
B L K Super speciality Hospital, Director
Centre for Thyroid, Breast and
Endocrine Disorders
Enterocutaneous fistulas
Dr Tarun Mittal
Consultant- Surgery, Sir Gangaram
Hospital, New Delhi
Peri-anal skin Diseases
Dr. Pascal Dsouza
Dir. Prof. Dermatology,ESI PGIMER, Delhi
Solitary thyroid nodule
Dr Chintamani
Professor, Dept of Surgery, VMMC,
New Delhi
Pancreatic endocrine tumors
Dr Sundeep Saluja
Professor, GI Surgery, GB pant
Aesthetic surgery Dr. Rajat
Gupta Consultant- Cosmetic
Surgery RG Aesthetics/
Pentamed
Non scalpel vasectomy
Dr. RCM Kaza
Rtd Dir Professor Surgery, MAMC
Currently Senior Consultant & DNB
Coordinator, Max Hospital, Vaishali
Neoadjuvant & Adjuvant therapy
in colorectal cancer
Dr Manoj Andley
Director Professor Surgery, LHMC, Delhi
Colonoscopy
Dr A S Puri
Gastroenterologist, Delhi, MBBS, MD, DM
Feeding jejunostomy
/gastrostomy Dr Naveen Sharma
Professor, Department of Surgery ,UCMS and
assoc. GTB Hospital, New Delhi
Soft tissue sarcoma of limbs
Dr Jainendra Arora
Professor, Surgery, VMMC and
Safdarjung Hospital, New Delhi
CA Anal canal
Dr. Kishore Singh
Director Professor and HOD, Radiotherapy
Maulana Azad Medical College
and assoc. Lok Nayak Hospital, New Delhi
MRI for surgeons
Dr Anjali Prakash
Professor, Dept of Radiology, MAMC
Pheochromocytoma
Dr Ajay Khanna
Professor, Dept of Surgery, BHU, Banaras
Emergency airway management
for surgeons
Dr Rakesh Kumar
Professor, Dept of Anesthesia, MAMC
Common X-rays for
surgeons Dr.Amit Gupta
Additional Professor
Dept. Of Surgery, AIIMS, Rishikesh
Investigations of peripheral vascular
disease
Dr. Rashmi Dixit
Professor, Radiodiagnosis, MAMC, Delhi
Management of peripheral vascular Varicose veins
disease Dr GJ Singh
Dr Shaji Thomas Director Professor Surgery, LHMC, Delhi
Director Professor Surgery, LHMC, Delhi

Thromboprophylaxis & Management of Renal cell carcinoma

DVT Dr Sanjay Gupta
Dr Rekha Porwal Dir Prof, Dept of Surgery, UCMS, New Delhi
Sr. Professor and Head
Department Of Surgery, J.L.N Medical
College Ajmer, Rajasthan

Bladder Cancer Prostate cancer

Dr Gagan Gautam Dr Rishi Nayyar
Consultant- Urology, Max Superspeciality , Associate Professor Urology, AIIMS, Delhi
Saket, New delhi

Erectile dysfunction PCNL

Dr Iqbal Singh Dr. Sanjay Gupta
Professor Urology, UCMS & GTB, Delhi Dir Prof, Dept of Surgery, UCMS, New Delhi

TURP Urodynamics
Dr Rajeev Sood Dr. Santosh Agarwal
Professor and Head of Department,Urology Associate Professor, Department of Urology
RML Hospital, New Delhi and renal transplant,
SAMC and PG Institute, Indore, MP

URS, IRIS and OIU Surgical Meshes

Dr Mrinal Pahwa Dr Deborshi Sharma
Consultant Urologist, SGRH, Delhi Professor ,Surgery, PGIMER- RML Hospital

Laparoscopic hernia repair Diagnostic laparoscopy

Dr Anubhav Vindal Dr Lovenish Kumar
Professor, Dept of Surgery, MAMC, Delhi Assistant Professor, Dept of Surgery, MAMC,
Delhi

Component separation Neck Dissection

Dr Romesh Lal Dr. Pankaj Kr Garg
Dir Professor of Surgery, LHMC and Dr. Professor
R.M.L.Hospital, New Delhi. Department of Surgery, UCMS, New Delhi

Periampullary Carcinoma Bariatric surgery

Dr. Vivek Mangla Dr Pawanindra lal
Associate Consultant Director Professor, Department of General
Surgical Gastroenterology & Liver Surgery, MAMC
Transplantation
Sir Gangaram Hospital

Lap cholecystectomy Lap CBD exploration

Dr Nitin Agarwal Dr Jagdish Chander
Associate professor, PGIMER - RML Director MAS, Jaypee Hospital
Hospital
RND Interventional Radiology
Dr. Ishwar Singh Dr Pushpender Khera
Director Professor, Department of ENT, Additional Professor and Head, Department of
Maulana Azad Medical College, New Delhi Radiology, AIIMS, Jodhpur

Options for duodenal ulcer perforation Crohn’s disease

management Dr Nikhil Talwar
Dr Sushanto Neogi Associate Professor, LHMC
Professor, Department of surgery, MAMC

Robotic Surgery Management of Benign Hypertrophy of

Dr Vivek Bindal prostate
Consultant Robotic Surgeon, SGRH, Delhi Dr. Lovekesh
Assistant Professor, Department of General
General Surgery, MAMC

Burns management and skin grafting Lap TEP

Dr. P. S. Bhandari Dr. Trilok Chand
Professor & HOD, Department of Burns & Assistant Professor, Department of General
Plastics, MAMC Surgery, MAMC
S. No Page
Title Author No
1. Malrotation of gut 1
Dr. Shandip Sinha
2. Undescended testes 5
Dr. Raman Kataria
3. Current classification and staging of breast cancer 11
Dr. Anurag Srivastav
4. Management of a patient with early breast cancer 13
Dr. P. N. Agarwal, Dr. Bhuwan Verma
5. Management of a patient with locally advanced breast cancer 16
Dr. Geeta
6. Management of a case with metastatic breast cancer 21
Dr. Kum Kum Singh
7. Sentinel L N. biopsy 23
Dr. Ishan Mohan
8. Mastectomy 25
Dr.Rajdeep Singh
9. Axillary dissection 30
Dr. Anurag Mishra
10. Breast reconstruction 33
Dr. Raghav Mantri
11. Ca tongue 35
Dr. Nitin Leekha
12. Achalasia cardia 39
Dr. Lalit Aggarwal
13. Hyperparathyroidism 46
Dr. Vivek Agarwal
14. Chest trauma 48
Dr. Subodh Kumar
15. Premalignant conditions of colon 53
Dr. Deepak Ghuliani
16. Investigations and Staging of colorectal cancer 65
Dr. Ashish Jakhetiya
17. Neoadjuvant & Adjuvant therapy in colorectal cancer 72
Dr. Manoj Andley
18. Surgical options for colorectal cancer 74
Dr. PK Mishra
19. Colonoscopy 77
Dr. Pawan Lal, Dr. Rohit Kaushik
20. Ileostomy / colostomy 82
Dr. Nikhil Gupta
21. Feeding jejunostomy /gastrostomy 84
Dr. Pawan Lal, Dr. Nisha Gautam
22. Thyroidectomy 86
Dr. Vivek Agarwal
23. Soft tissue sarcoma of limbs 91
Dr. Jainendra Arora
24. Enterocutaneous fistulas 104
Dr. Tarun Mittal
25. CA anal canal 107
Dr. Kishore Singh
26. Peri-anal skin Diseases 117
Dr. Pascal Dsouza
27. MRI for surgeons 123
Dr. Anjali Prakash
28. Solitary thyroid nodule 128
Dr. Chintamani
29. Pheochromocytoma 133
Dr. Ajay Khanna
30. Pancreatic endocrine tumours 138
Dr. Sundeep Saluja
31. Emergency airway management for surgeons 146
Dr. Rakesh Kumar
32. Aesthetic surgery 149
Dr. Rajat Gupta
33. Common X-rays for surgeons 159
Dr. Amit Gupta
34. NSV 164
Dr. R C M Kaza
35. Investigations for peripheral vascular disease 172
Dr. Rashmi Dixit
36. Management of peripheral vascular disease 173
Dr. Shaji Thomas
37. Varicose veins 179
Dr. GJ Singh
38. Thromboprophylaxis & Management of DVT 190
Dr. Rekha Porwal
39. Renal cell carcinoma 196
Dr. Pawan Lal, Dr. Pranav Mohan Singhal
40. Bladder Cancer 199
Dr. Gagan Gautam
41. Prostate cancer 208
Dr. Rishi Nayyar
42. Erectile dysfunction 215
Dr. Iqbal Singh
43. PCNL 220
Dr. Pawan Lal, Dr, Sumit Agrawal
44. TURP 223
Dr. Rajeev Sood
45. Urodynamics 225
Dr. Santosh Agarwal
46. URS, IRIS and OIU 228
Dr. Mrinal Pahwa
47. Surgical Meshes 234
Dr. Deborshi Sharma
48. Laparoscopic hernia repair 240
Dr. Anubhav Vindal
49. Diagnostic laparoscopy 250
Dr. Lovenish Kumar
50. Component separation 263
Dr. Romesh Lal
51. Neck Dissection 267
Dr. Pankaj Kr Garg
52. Periampullary Carcinoma 272
Dr. Vivek Mangla
53. Bariatric surgery 280
Dr. Pawanindra Lal
54. Lap cholecystectomy 292
Dr. Nitin Agarwal
55. Lap CBD exploration 296
Dr. Jagdish Chander
56. Interventional Radiology 304
Dr. Pushpender Khera
57. Options for duodenal ulcer perforation management 309
Dr. Sushanto Neogi
58. Crohn’s disease 313
Dr. Nikhil Talwar
59. Robotic Surgery 320
Dr. Vivek Bindal
60. Management of Benign Hypertrophy of prostate 331
Dr. Lovekesh
61. Burns management and skin grafting 342
Dr. P. S. Bhandari
62. Laparoscopic Groin Hernia Repair (TEP) 346
Dr. Trilok Chand
63. Renal Stones 351
Dr. Pawan Lal, Dr. Mehul Agarwal
 MALROTATION OF GUT
-Dr Shandip Kumar Sinha

Definition- A group of abnormalities because of abnormal rotation and fixation of intestine is known as
malrotation.
Demographics of diagnosis
First week of life 40%
First week to 1 months 10%
1 months to 1 year 25%
1 years to late adulthood(symptoms, contrast X rest 25%
rays, intraoperatively or at autopsy)

Clinical presentation- the presentation can be grouped into one of the constellations
Acute midgut volvulus
Chronic midgut volvulus
Acute duodenal obstruction
Chronic duodenal obstruction
Internal herniation

Acute Midgut Volvulus

Most patients present in the first year of life.
The primary presenting sign of acute midgut volvulus is sudden onset of bilious emesis.
Bilious vomiting in the newborn is a sign of intestinal obstruction until proved otherwise.

Chronic Midgut Volvulus

Chronic midgut volvulus is due to intermittent or partial twisting that results in lymphatic and
venous obstruction.
Multiple case reports show that 2 of the main presenting features are recurrent abdominal pain
and malabsorption syndrome.
Several patients presented with acute midgut volvulus, but further history revealed they had
had chronic symptoms with misdiagnoses.
Other clinical features include recurrent bouts of diarrhea alternating with constipation,
intolerance of solid food and gastro esophageal reflux.

Acute Duodenal Obstruction

This anomaly is usually recognized in infants and is due to compression or kinking of the
duodenum by peritoneal bands (Ladd bands).
Patients present with forceful vomiting, which may or may not be bile-stained, depending on
location of the obstruction with respect to the entrance of the common bile duct (ampulla of Vater)
.

The typical age at diagnosis ranges from infancy to preschool-age.

The most common symptom is vomiting, which is usually bilious.
Patients may also have failure to thrive and intermittent abdominal pain (frequently diagnosed
as colic). Internal Herniation
Internal herniation usually has a chronic picture.
Patients have recurrent abdominal pain, which may progress from intermittent to
constant. They experience vomiting as well as constipation at times.
They are often diagnosed with psychosocial problems.
Clinical findings
Physical examination findings may vary depending on the type of rotational defect. Acute and chronic
presentations also differ.

Acute midgut volvulus

Abdominal distention is frequently present, and the infant appears in acute pain.
As vascular compromise persists, intraluminal bleeding may occur, which leads to blood per
rectum and sometimes hematemesis.
Abdominal guarding is usually present and prevents palpation of intestinal loops.

1
 As symptoms persist, the infant may develop signs of shock, including poor perfusion,
decreased urine output, and hypotension.
Patients also have signs of peritonitis, including abdominal tenderness and discoloration of the skin.

Chronic midgut volvulus

Physical examination results may be completely normal if the patient presents during a period
when the obstruction is relieved.
If partial twisting is present at the time of examination, the patient may have signs and
symptoms equivalent to those of acute midgut volvulus.
Abdominal tenderness and guarding is usually present, as well as abdominal distention.

Acute duodenal obstruction

Abdominal distention and gastric waves may be present.
Passage of meconium or stool can be present.
These patients usually do not have signs of peritonitis or shock unless volvulus is also present
distal to the obstruction.

Physical examination results may be completely normal at the time of

presentation. Abdominal distention and tenderness may be present.
Diagnosis is usually made by history and enough suspicion to obtain radiologic studies;
physical examination findings are very unreliable.

Internal herniation
Physical examination findings can be unremarkable, and diagnosis is made by radiologic
studies and index of suspicion only.
Patients with left mesentericoparietal hernias may have findings related to venous obstruction,
such as hematochezia, hemorrhoids, and dilated anterior abdominal veins.
If the bowel of the patient is obstructed at the time of presentation, abdominal tenderness and
guarding may be present, and a soft globular mass may be palpated at the location of the hernia.

EMBRYOLOGY
During normal abdominal development, the 3 divisions of the GI tract (i.e. foregut, midgut, and hindgut)
herniate out from the abdominal cavity, where they then undergo a 270º counterclockwise rotation around
the superior mesenteric vessels. Following this rotation, the bowels return to the abdominal cavity, with
fixation of the duodenojejunal loop to the left of the midline and the cecum in the right lower quadrant. The
cause of intestinal malrotation is disruption in this normal embryological development of the bowel.
Stage I - 4–10 weeks: midgut protrudes and develops in the physiological umbilical hernia.
Stage II 10–12 weeks: midgut migrates back into the abdomen in an orderly manner, small
bowel first and cecocolic loop last. The cecum initially lies on the left but it rotates through
270° to attain its final position in the right iliac fossa. Simultaneously, the duodenum
undergoes a 270° anti-clockwise rotation.
Stage III Final phase consisting of fusion of various parts of the mesentery with fixation of
cecum and ascending colon and the descending colon.
•Nonrotation: Arrest in development at stage I results in nonrotation. Subsequently, the duodenojejunal
junction does not lie inferior and to the left of the SMA, and the cecum does not lie in the right lower
quadrant. The mesentery in turn forms a narrow base as the gut lengthens on the SMA without rotation, and
this narrow base is prone to clockwise twisting leading to midgut volvulus. The width of the base of the
mesentery is different in each patient, and not every patient develops midgut volvulus.
•Incomplete rotation: Stage II arrest results in incomplete rotation and is most likely to result in duodenal
obstruction. Typically, peritoneal bands running from the misplaced cecum to the mesentery compress the third
portion of the duodenum. Depending on how much rotation was completed prior to arrest, the mesenteric base
may be narrow and, again, midgut volvulus can occur. Internal herniations may also occur with incomplete
rotation if the duodenojejunal loop does not rotate but the cecocolic loop does rotate. This may trap most of the
small bowel in the mesentery of the large bowel, creating a right mesocolic (paraduodenal) hernia.
•Incomplete fixation: Potential hernial pouches form when the mesentery of the right and left colon
and the duodenum do not become fixed retroperitoneally. If the descending mesocolon between the
inferior mesenteric vein and the posterior parietal attachment remains unfixed, the small intestine may
push out through the unsupported area as it migrates to the left upper quadrant. This creates a left
mesocolic hernia with possible entrapment and strangulation of the bowel. If the cecum remains
unfixed, volvulus of the terminal ileum, cecum, and proximal ascending colon may occur

CBC count
An elevated or decreased WBC count may indicate sepsis as a reason for abdominal
distention and bilious emesis.
2
 A decreased platelet count may indicate a platelet consumptive process (eg, necrotizing
enterocolitis).
A decreased hemoglobin/hematocrit gives evidence of blood loss, possibly through GI bleeding.
Arterial, capillary, or venous blood gas: Metabolic acidosis provides evidence for ongoing
ischemia as observed with necrotizing enterocolitis or strangulated bowel (volvulus).
Blood chemistries
Correct any electrolyte imbalances if possible prior to surgery.
Ongoing sodium, chloride, and bicarbonate losses occur through suctioned GI secretions.
Furthermore, patients may have increased potassium levels due to metabolic acidosis and hemolysis.
Blood grouping and cross matching: Keep this test current because these infants often need emergent
surgery and may need blood replacement.
Prothrombin time (PT) and activated partial thromboplastin time (aPTT): Perform clotting
studies in older infants and children in whom surgery is highly likely.

Plain radiography has limited use for defining obstruction because infants may have a gasless
abdomen or one that is almost normal.
Features suggestive of malrotation with or without midgut volvulus are a distended stomach
and proximal duodenum with a paucity of gas distally, either throughout or unilaterally.

Upper GI series is the study of choice in patients who are stable

Normal rotation is present if the duodenal C-loop crosses the midline and places the duodeno
jejunal junction to the left of the spine at a level greater than or equal to the pylorus.
Bases on UGI contrast finding two types ahd been described
Typical- if ligament of Treitz right of midline or absent
Atypical- if ligament of Treitz in midline or to the left and below the gastric outlet/pylorus
If contrast ends abruptly or tapers in a corkscrew pattern, midgut volvulus or some other form
of proximal obstruction may be present.
Barium is the contrast of choice in patients who are stable or have chronic symptoms.
Contrast studies may not be possible in patients who are actively vomiting or are otherwise
unstable and need immediate surgical exploration. Water-soluble agents should be used if the
study must be performed prior to imminent surgery.

Lower GI series (contrast enema)

Occasionally, upper GI series findings may be indeterminate for the location of the duodenojejunal
junction. In these cases, lower GI series may be used to identify location of the cecum.
Lower GI series can also rule out colonic obstruction and ileal atresia. However, a normally placed
cecum does not unequivocally rule out a malrotation, and clinical judgment must be exercised.

Ultrasonography
In the hands of experienced ultrasonographers, ultrasonography has been shown to be very
sensitive (approximately 100%) in detecting neonatal malrotation.
Highest sensitivity is achieved when inversion of the superior mesenteric artery (SMA) and the
superior mesenteric vein (SMV) is shown.
Other diagnostic findings are fixed midline bowel loops and duodenal dilation with distal
tapering. Also, volvulus is highly probable if the SMV is shown to be coiling around the SMA.
All features are enhanced if water is instilled first by nasogastric (NG) tube.
The presence of ascites and thickened bowel wall were not found to be statistically significant
predictors of malrotation with midgut volvulus.

CT scanning
CT scanning is not well developed for diagnosing malrotation and midgut volvulus.
Scattered case reports of its use are noted, but it is not recommended as the principal diagnostic tool.
Whirlpool flow pattern in Superior mesenteric vein around superior mesenteric artery had been reported

Management
Insert an NG tube in all patients with bilious emesis and suspected
malrotation. IV access.
Medical care of intestinal malrotation is directed toward stabilizing the patient.
Where malrotation with volvulus or obstruction is suspected, seek immediate pediatric surgical
consultation.
Correct fluid and electrolyte deficits.
3
 Administer broad-spectrum antibiotics prior to surgery, if possible.
If a patient has signs of shock, administer appropriate fluids, blood products, and vasopressor
medications to improve hypotension.
If the patient is unstable, do not delay surgical intervention for upper GI and laboratory studies.
Quick surgical intervention, not prolonged medical management, produces the best results if
midgut volvulus is suspected.

The Ladd procedure remains the cornerstone of surgical treatment for malrotation today. Prior to
William Ladd's publication in 1936, surgical treatment for malrotation with or without volvulus had a
mortality rate higher than 90%. A classic Ladd procedure is described as
Reduction of volvulus (if present),
Division of mesenteric bands,
Placement of small bowel on the right and large bowel on the left of the
abdomen, Appendectomy.

If midgut volvulus is present, the entire small intestine along with the transverse colon is
delivered out of the abdominal incision, where the volvulus can be reduced.
Because the volvulus usually twists in a clockwise direction, reduction is accomplished by
twisting in a counterclockwise direction.
After the blood supply has been restored by detorsion, the surgeon must make a decision
about viability of the involved bowel. The outcome is better when no gangrenous bowel is
present or when a small localized gangrenous segment is present, which can be resected and
a primary anastomosis performed.
Enterostomy is performed when questionable viability is observed at the ends of a gangrenous
area that is resected.
If multiple areas of questionable viability are present, many surgeons choose to leave the areas and
perform a second-look operation in 12-24 hours if the patient is not showing clinical recovery.

After the volvulus is reduced or if no volvulus was present, identify any extrinsic obstruction to
the duodenum.
If peritoneal bands crossing the duodenum are found, ligate them with careful attention to
protecting the superior mesenteric vessels. The bands may also obstruct the ileum or the
jejunum and sometimes run to the gallbladder and liver.
Extrinsic obstruction may also be due to the cecum, colon, or superior mesenteric artery (SMA)
impinging on the duodenum; relief is obtained by placing the cecum with its mesentery in the
left upper quadrant and exposing the anterior duodenum through its entire length.
After extrinsic obstruction has been relieved, determine that no intrinsic obstruction exists by
passing an NG tube through the duodenum.

Frequently, dissection of the peritoneal bands causes damage to the appendiceal vessels.
Therefore, surgeons perform an appendectomy prior to closure.
Appendectomy is also advisable because the normal anatomical placement of the appendix is
disrupted when the cecum is placed on the left side of the abdomen.

Laparoscopy
Laparoscopy has been used to repair malrotation with signs of duodenal obstruction but no
midgut volvulus.
The Ladd procedure, including widening of the mesenteric base and dissection of peritoneal
bands, has been performed successfully and has resulted in shorter hospital stays.
Laparoscopic Ladd procedure has been reported more frequently in the literature and is
becoming more accepted as an initial approach to surgical correction. A retrospective analysis
of both open and laparoscopic Ladd procedures performed at the Children's Hospital of Illinois
in Peoria noted that short-term results were superior with the laparoscopic approach and can
be achieved without any increase in operative duration.

Atypical malrotation
If ligament of Treitz in midline or to the left and below the gastric outlet/pylorus, it is known as atypical
malrotation. Asymptomatic patients with incidentally discovered Typical malrotation (found at
radiography or surgery) should, regardless of their age, have prompt corrective surgery if a narrow
base to the midgut mesentery is suspected. However, minor degrees of incomplete rotation are
relatively common and the management of these patients is controversial, e.g., a child with minor
nonspecific abdominal pain who is investigated by an uppergastrointestinal contrast study and found
to have a duodenojejunal flexure in a low midline position and acecum in the right lower quadrant. The
risk of volvulusin this case is very low and surgery is unlikely to bebeneficial.
4
Some older patients with atypical and chronicsymptoms do not benefit from correction of atypical
malrotation. In some of these, malrotation is probablythe consequence of a primary abnormality in
gutmotility rather than the root cause of symptoms.

Long term prognosis

Successful surgery had universally good prognosis. Recurrence of midgut volvulus is extremely rare
but adhesion intestinal obstruction is not uncommon with a relative risk around 8–10%.

UNDESCENDED TESTIS
-Dr. Raman Kataria
Undescended Testis is one of the commonest surgical problems encountered in children, though often they
may present in adulthood. A testis that does not descend completely along the normal course of descent to
reach its final scrotal location is Undescended. It may be supra scrotal, at the superficial inguinal ring or in
the inguinal canal, all of which would usually be palpable. However, testis located higher in the inguinal
canal (peeping) or those which are at the deep ring or intra-abdominal, are impalpable. The scrotum is
empty and underdeveloped. The term cryptorchidism (hidden testis) is often used interchangeably, though
it would be more appropriate for impalpable undescended testis. An empty scrotum may also result from
ectopic testis (most commonly in the sub-inguinal pouch, but rarely in the perineum, at the penile base, or
opposite scrotum), retractile testis (due to hyperactive cremasteric reflex but can be brought down into the
scrotum completely), ascended testis (which ascend after birth due to differential somatic growth),
retained/retracted testis (secondary to surgical intervention or trauma), vanishing testis (secondary to intra-
uterine testicular torsion and atrophy/resorption) or extremely rarely testicular agenesis (where Mullerian
structures will persist on the affected side).

The prevalence of undescended testis is nearly 4% at birth, with rates being much higher in preterm
and low birth weight babies (10-45%). However the prevalence reduces to nearly 1% by one year age.
The left side is affected more (60%) than the right (30%), while it is bilateral in 10% cases.

Embryology of testicular descent and Maldescent

The human gonadal ridge containing somatic and germ cells is first identified on the medial urogenital
ridge at 32 days after ovulation. Gonadal determination involves separate genetic pathways for
development of testis and ovary. Primordial germ cells migrate from the yolk sac and differentiate into
gonocytes during the 5th week of gestation. SRY (sex-determining region Y) is a master switch in
males that regulates downstream testis-determining genes. Expression of the earliest testis (Sertoli
cell)-specific genetic markers, SRY and SOX9 (SRYbox 9), begins at between 41 and 44 days, followed
by the histological appearance of Sertoli cells and testicular cords in male foetuses by 9 weeks of age.
Differentiation of gonocytes and Sertoli and Leydig cells occurs at 5 to 9 weeks’ gestation, and the
gubernaculum, the guide for testicular descent, appears at 7 weeks’ gestation.
Levels of the Leydig cell hormones, testosterone and INSL3 (Insulin-like 3) peak at 14 to 17 weeks’
gestation and are critical for masculinisation of the reproductive tract and testicular descent. The secreted
androgens from the testis, is responsible for the differentiation of the Wolffian duct into the epididymis, vas
and lower down to form a bud for the development of the seminal vesicles. Secretion of MIS by the Sertoli
cells inhibits Mullerian duct development in the male. Swelling of the gubernaculum, which starts in the
second trimester, provides space for passage of the testis into the scrotum at 20 to 28 weeks’ gestation.
Barteczko and Jacob (2000) described five major phases of testicular descent in the human foetus, as
below. Phase 1:The caudal mesonephros contacts the future gubernaculum at the internal inguinal
ring (5 weeks’ gestation).
Phase 2:The genitofemoral nerve accompanies the newly formed gubernaculum (abdominal,
interstitial, and subcutaneous portions) and processus vaginalis (7 weeks).
Phase 2a:Growth of the gubernaculum, deepening of the processus vaginalis and extension of
cremaster muscle fibres into the interstitial gubernaculum occurs (8 to 10 weeks).
Phase 3:Growth of the testis and regression of the müllerian ducts and mesonephros occurs; the
gubernaculum remains a thin cord in both sexes (10 to 12 weeks).
Phase 3a:The testis overrides the genital ducts and contacts the gubernaculum, which begins its
swelling phase in males (12 to 14 weeks).
Phase 4:Swelling of the gubernaculum, development of the cremaster muscle, and migration of the
processus vaginalis produce widening of the inguinal canal (14 to 20 weeks).

5
Phase 5:Release of the distal subcutaneous attachment of the gubernaculum and transinguinal
passage of the testis occurs (20 to 28 weeks).
Phase 5a:Further caudal movement of the testis into the scrotum is accompanied by regression of the
gubernaculum (7th month and beyond).
Thus, normal testicular descent occurs in two separate stages with differing hormonal control (Hutson
and Hasthorpe).
The Transabdominal phase between 8 to 15 weeks of gestation: The primitive gonad in Urogenital ridge turns into
testis by the gene in short arm of Y chromosome (SRY) around 5-6 weeks. The early testis produces three
hormones 1. Testosterone from Leydig cells which induces regression of the cranial suspensory ligament and
Cranial Mesonephric ligament. 2. Mullerian Inhibiting Substance (MIS) from the Sertoli cells which induce Mullerian
duct regression. 3. Insulin-like 3 Hormone which causes thickening of caudal Gubernaculum that holds the testis
close to inguinal abdominal wall causing relative descent of testis as somatic growth occurs.

The Inguino-scrotal phase of testicular descent between 28-35 weeks of gestation: The processus vaginalis
elongates into gubernaculums at 25 weeks. The distal end of the gubernaculum then elongates to reach the
scrotum between 30-35 weeks. The testis then descends through the patent processus vaginalis. This probably
happens under the influence of Testosterone along the Genitofemoral nerve that is known to produce Calcitonin
Growth Related Peptide (CGRP). This induces the migration of gubernaculum with testis into scrotum. Certain
mechanical factors that help in testicular descent include shortening and traction of the gubernaculum testis,
elongation of the processus vaginalis, intra-abdominal pressure from increasing visceral size, straightening of
foetus, resolution of physiological hernia, testicular enlargement and growth of epididymis, and the propulsive
force of the developing cremasteric muscle. Failure of any of these mechanisms may cause testicular non-descent
or maldescent, though hormonal factors in the inguino-scrotal phase seem to be deranged more often.

Non-syndromic undescended testis is by far the commoner, though a significant proportion can be
syndromic. The prevalence of non-syndromic undescended testis at birth is 2% to 4% and at 3 months
of age reduces to 1% to 2%, and this varies geographically. Perinatal risk factors associated with
cryptorchidism include prematurity, low birth weight/small forgestational age, breech presentation,
and maternal diabetes.Spontaneous postnatal testicular descent occurs in 50% to 75% infants and is
more likely and may occur later in premature infants. Careful, often serial, physical examination may
be necessary to accurately determine testicular position and need for intervention. Genetic
susceptibility is likely polygenic (autosomal dominance with reduced penetrance) and multifactorial.
The Recurrence risk ratio (RR) was 10.1 in twins, 3.5 in brothers, and 2.3 in offspring.

Environmental factors: A correlation between exposure to anti-androgenic and/or estrogenic

endocrine disrupting chemicals (EDCs) such as pesticides, flame retardants, and phthalates and
occurrence of cryptorchidism has been shown. Testicular dysgenesis syndrome is the term used to
describe a potentially related constellation of reproductive abnormalities including cryptorchidism,
hypospadias, infertility, and Testicular Germ Cell Tumour (TGCT) (Sharpe and Skakkebaek, 2008). The
proposed cause is a deficiency in foetal androgen production resulting from exposure to EDCs.
However, at present, epidemiologic data are suggestive but do not strongly support thetheory that
environmental chemicals increase susceptibility to cryptorchidism.

Syndromic Cryptorchidism
Undescended testes are frequently present in diseases associated with reduced androgen production
and/or action, such as androgen biosynthetic defects, androgen insensitivity, Leydig cell agenesis, and
gonadotropin deficiency disorders. AMH biosynthesis or receptor defects are also associated with
cryptorchidism or transverse testicular ectopia (Josso et al, 2006). Certain anomalies are associated with
increased risk of cryptorchidism, many related to musculoskeletal, central nervous system (CNS), or
abdominal wall/gastrointestinal defects. These include all cases of classic prune-belly triad or Eagle-Barrett
syndrome; 80% of those of spigelian hernia; and 41% to 54% of cerebral palsy; 38% of arthrogryposis; 15%
of myelomeningocele, 16% to 33% of omphalocele, 5% to 15% of gastroschisis, 19% of imperforate anus,
12% to 16% of posterior urethral valve, and 6% of umbilical hernia patients.

Diagnosis and Classification

To best determine testicular position, boys should be examined in supine and, if possible, upright cross-legged
and standing positions. Abduction of the thighs contributes to inhibition of the cremaster reflex. The examination
should include documentation of testicular palpability, position, mobility, size, and possible associated findings
such as hernia, hydrocele, penile size, and urethral position. Clinically, the majority (75% to 80%) of undescended
testes are palpable and 60% to 70% are unilateral; involvement of the right side is more common overall. In a
comprehensive review of surgical patients, testes were abdominal in 34%, near the internal ring (“peeping”) in
12%, canalicular in 27%, and beyond the external ring in 27% (Docimo, 1995).
If both testes are nonpalpable, particularly if penile development is abnormal, karyotype and hormonal
analyses are performed to rule out congenital adrenal hyperplasia and obviate the potential adverse
effects of undiagnosed salt wasting.
6
Hypospadias is associated with cryptorchidism in 12% to 24% of cases (Cendron et al, 1993; Moreno-Garcia and
Miranda, 2002; Cox et al, 2008). If proximal hypospadias is present, chromosomal analysis is warranted because
the frequency of abnormalities is high (32%) (Cox et al, 2008). Penile size may be small in boys with bilateral
vanishing testes (also called testicular regression syndrome) or with hypogonadotropic hypogonadism, in whom
undescended testes are most commonly inguinal. In these cases, measurement of testosterone, LH, and FSH
levels in the first few months of life can facilitate identification of hormone deficiency or anorchia.

During palpation one must look for testis along the line of descent by milking from close to the ASIS
medially and downwards with the non-dominant hand, as the other hand palpates the scrotum and
inguinal region for testis. Ectopic position of testis is most commonly the superficial inguinal pouch
(anterior to the rectus abdominis muscle), or more rarely, in a perirenal, prepubic, femoral, peripenile,
perineal, or contralateral scrotal position (Fig above). Careful examination of these areas is needed to
correctly classify a testis as palpable or nonpalpable.
When a testis is nonpalpable, possible clinical findings at surgery include (1) abdominal or
transinguinal “peeping” location (25% to 50%), (2) complete atrophy (“vanishing” testis, 15% to 40%),
and (3) extra-abdominal location but nonpalpable due to body habitus, testicular size, and/or limited
cooperation of the patient (10% to 30%). Diagnosis of a vanishing testis requires documentation of
blind-ending spermatic vessels in the abdomen, inguinal canal, or scrotum.
Inguinoscrotal ultrasonography and magnetic resonance imaging (MRI) are not indicated for diagnosis of
the nonpalpable testis, because they have limited accuracy and do not obviate the need for definitive
surgical intervention.Diagnostic laparoscopy followed by laparoscopic orchidopexy, if the testis is
abdominal has become the preferred approach. The need for contralateral fixation of a solitary testis in
cases of monorchism is not clear. The possibility that prenatal torsion is the etiology of vanishing testis
(Gong et al, 1996) does not imply that the contralateral testis is likely to undergo a similar fate after the
postnatal period. However, some surgeons recommend contralateral fixation to eliminate the risk of such a
devastating complication (Rozanski et al, 1996), and/or because a contralateral bell-clapper deformity
(incomplete testicular fixation to the tunica vaginalis), may be present.

Associated pathology with testicular Maldescent: The number of spermatogonia per tubule (S/T) is reduced
after infancy and fails to increase normally with age in cryptorchid and, to a lesser degree, in contralateral
scrotal testes. The frequency of abnormal histology in the contralateral testis varies between studies,
ranging from 22% to 95%. There is strong evidence that abnormal germ cell developmentis often present
after early infancy in cryptorchid testes. Impaired transformation of gonocytes to spermatogonia is reported
in cryptorchid testes and may help define fertility potential. In normal testes, germcell number decreases
after birth as gonocytes either degenerate by apoptosis or migrate to the basement membrane and
differentiate into spermatogonia (Hadziselimovic et al, 1986; Huff et al, 2001). Although the ratio of
gonocytes to spermatogonia appears to be normal in cryptorchid testes at about 1.5 months of age, delayed
disappearance of gonocytes and appearance of adult dark (Ad) spermatogonia occurs in the undescended
as compared with the contralateral descended testis. Ad spermatogonia are likely the reserve stem cells of
the germ cell pool (Dym et al, 2009).

Kollin and colleagues (2006, 2007) studied testicular growth in undescended and scrotal testes and
measured the effect of orchidopexy on testicular size using serial ultrasonography in prospective
randomized studies. They showed that the undescended testis is not significantly smaller at birth but
grows less well than the scrotal testis, and orchidopexy at age 9 months allows partial catch-up
growth of the cryptorchid testis up to 4 years of age. In contrast, testes that remained cryptorchid until
3 years of age did not grow significantly before or after orchidopexy.

7
The epididymis is often abnormal in boys with cryptorchidism (Marshall and Shermeta, 1979), with a reported
frequency of 35% to 75% (Fig above). Anomalies of the tunica and processus vaginalis incryptorchidism
predispose to development of testiculartorsion or clinical hernia. Persistently patent processus vaginalis
ipsilateral has been noted in 87% of unilateral undescended testis. Torsion of an undescended testis can occur at
any age (reviewed by Zilberman et al, 2006) and may be confused with an incarcerated inguinal hernia. The risk of
torsion is much higher in an undescended as compared with a descended testis and may be particularly high in
children with neuromuscular disease such as cerebral palsy.

Treatment:

Why Treat?
Correction of cryptorchidism is indicated to optimize testicular function, potentially reduce and/or
facilitate diagnosis of testicular malignancy, provide cosmetic and psychologic benefits, and prevent
complications such as clinical hernia or torsion.

When and How to Treat?

If descent does not occur in the postnatal period, present consensus supports surgical treatment at 6
months of age. Support for this approach is based on the following rationale:-
descent is unlikely in full-term males after age 6 months (Wenzler et al, 2004);
testicular growth is restored after early orchidopexy (Kollin et al, 2007);
hormone therapy is not considered efficacious (Ritzen et al, 2007); and
Orchidopexy for abdominaltestes may be facilitated in young infants soon after the hormonal surge.
In boys with a history of prematurity, spontaneous descent may be delayed and therefore continued
observation for 6 months beyond the expected date of delivery or, especially if testicularposition is
marginal, until a year of age may be warranted.
However, even if spontaneous descent occurs, continued observation is needed because of the risk
for recurrent cryptorchidism, or “re-ascent” of a spontaneously descended testis. Observation is not
recommended for acquired cryptorchidism.

Hormonal therapy has been used for a variety of indications in patients with cryptorchidism, including
differentiation of retractilefrom true undescended testes, stimulation of testicular descentor germ cell maturation,
and as an adjunct to abdominal orchidopexy. However, data suggest that hCG fails to reliably distinguish retractile
from cryptorchid testes and therefore does not eliminate the need for serial examinations in these patients. LH-
releasing hormone (LHRH) and/or hCG have been used as hormonal therapy to induce descent of testes for more
than 70 years based on the premise that androgens promote testicular descent, but the efficacy of this therapy is
questionable. Overall, the evidence from rigorous studies indicates that LHRH therapy for cryptorchidism is only
marginally more effective than placebo; although not studied in randomized placebo controlled trials because of
its route of administration, hCG also shows limited efficacy.
A recent statement by the Nordic Consensus group recommends that testicular biopsy and hormonal
therapy not be used in standard clinical care of boys with cryptorchidism.

Surgical Approach:
The standard treatment for palpable testes is inguinal orchidopexy with repair of an associated hernia
if present. The recommended age for surgical intervention has gradually declined over the years and
presently is age 6 months in full-term males in whom the testes have failed to descend.
An option for pubertal and post-pubertal boys is orchiectomy, especially if the testis is abdominal or
difficult to mobilize because poor spermatogenesis and hypotrophy are usually present and the risk of
carcinoma in situ and torsion exist (Rogers et al, 1998).

Inguinal Orchidopexy
After induction of anaesthesia, the patient is re-examined to confirm that the testis is palpable and to identify the
lowest testicular position. In the standard inguinal approach, a low transverse incision in Langer’s lines at or
below the inguinal crease is made supero-lateral to the pubic tubercle. Dissection of the subcutaneous tissue
should include a search for a testis within the superficial inguinal pouch. The external oblique fascia is incised to
expose the canal with care to avoid injury to the ilioinguinal nerve. Testis position is recorded relative to the
inguinal canal. The spermatic cord is isolated, and the testis is dissected distally to its attachment to the
gubernacular remnant. Transection of the gubernaculum distal to the sac will avoid potential injury to a long-
looping vas. Longitudinal incision of the internal spermatic fascia allows free mobilization of an intact hernia sac,
if present, and minimizes skeletonization of the vas and spermatic vessels. After transection, the sac is mobilized
to the level of the internal inguinal ring and suture ligated. Incision of the internal spermatic and transversalis
fascia at the level of the ring facilitates additional retroperitoneal mobilization of the vas and vessels, if needed.
Further maneuvers to provide spermatic cord length include transection of lateral fascial bands (Brown’s bands)
along the cord, cranial retroperitoneal dissection, medial transposition of the testis beneath the epigastric vessels
(Prentiss maneuver) and, if required, cranial extension of the incision. Very rarely, the testis cannot be brought to
dependent scrotal position after these maneuvers and a two-stage
8
procedure may be considered as an alternative to orchiectomy (which is preferentially reserved for
grossly abnormal or atrophic testes). Another novel two-stage technique for high canalicular or
abdominal testes involves placement of a polytetrafluoroethylene membrane around the mobilized
cord, fixation of the testis to the invaginated scrotum with a pledget, followed by a 9- to 12-month
delay that allowed spontaneous scrotal localization of the testis in 82% of 45 testes.
A large clamp or a finger can be used to create a tunnel just anterior to the pubis and a scrotal or subdartos
pouch created after transverse incision of the scrotal skin. The testis is passed through an opening in the
dartos without twisting of the spermatic cord. Existing appendages should be excised and the epididymis
inspected and any anomalies recorded. Recording of testicular volume by direct calliper measurement in
three dimensions and similar (estimated) measurements of contralateral testicular volume can establish a
baseline for postoperative assessment. Secure fixation of the testis within the pouch can be achieved by
tension-free closure of the opening in the dartos around the cord, incorporating the cut edge of the tunica
vaginalis. If needed, additional absorbable fixation sutures can be placed between the visceral tunica
vaginalis and the dartos. Sutures through the tunica albuginea of the testis are not recommended because
of possible injury to the testis via inflammatory or vascular insult; suture fixation of the testis is in any event
not needed if mobilization is adequate and a subdartos pouch technique is used.

Biopsy is indicated in cases of sexual ambiguity or if clinical evidence of testicular dysgenesis is present.
Complications of inguinal orchidopexy for a palpable testis are uncommon; those of greatest frequency and
concern include testicular retraction or atrophy. Implantation of a testicular prosthesis should be
considered and is preferably done after puberty. Clinical experience suggests that cryptorchid boys may
request prosthesis implantation less frequently than males with acute testicular loss after puberty.

Surgical Approach to the Abdominal Testis:

A peculiar feature of the vascular supply of the testis is the presence of 3 arteries- testicular, cremasteric and
artery to the vas, all anastomosed mainly at the head of epididymis. Hence ligation of the testicular artery is not
necessarily followed by testicular atrophy - a principle utilised for the Stephen Fowler’s Orchidopexy. Once an
abdominal testis has been identified by laparoscopy or other means, a decision is made whether to proceed with
an open or laparoscopic, one- or two-stage orchidopexy with or without spermatic vessel transection.
Orchiectomy is appropriate for patients with testes that are poorly viable and/or at higher risk for tumour, such as
very small or dysgenetic prepubertal or in post pubertal patients, and is best performed laparoscopically.

Laparoscopic Orchidopexy and Fowler-Stephens Orchidopexy.

Operative laparoscopy emerged over 20 years ago as the procedure of choice for abdominal orchidopexy
(Caldamone and Amaral, 1994; Jordan and Winslow, 1994), and the basic surgical approach and high success
rates have stood the test of time. The feasibility of primary versus Fowler-Stephens orchidopexy depends on the
length of the vas and vessels, presence or absence of looping ductal structures, and age of the patient. Although
laparoscopy allows the surgeon to assess some of these features before choosing a specific surgical procedure,
the choice may be difficult. For testes that are not near (variably defined as 2 to 4 cm above) the internal inguinal
ring, the Fowler-Stephens procedure is typically performed laparoscopically with spermatic vessel clipping
(Bloom, 1991) followed by laparoscopic or open testicular mobilization 6 months later or in one stage. Studies
have shown a reduction in adult testicular sperm numbers, following transection of spermatic vessels (both high
and low). Hence the preferred approach is avoidance of spermatic vessel transection whenever possible; the
available data suggest this is possible in the majority of cases of abdominal orchidopexy. Micro vascular
orchidopexy appears to be a preferred approach to the solitary abdominal testis, particularly with historical
success rates of 88% as compared with lower rates for open procedures. Even a venous anastomosis alone
without arterial anastomosis, is acceptable as testicular damage has been shown to occur because of testicular
congestion. This helps reduce operative time.

Follow up, Prognosis:

Fertility: Both Ad spermatogonia count and germ cell absence are potentially useful measures of fertility
prognosis, but may be more useful in cases of bilateral cryptorchidism. Chilvers and colleagues (1986) reported
overall rates of oligospermia and/or azoospermia in 75% of formerly bilaterally and 43% of formerly unilaterally
cryptorchid men. The limited available data comparing earlier (age <9 years) and later treatment did not show
differences in the frequency of sub fertility after unilateral (281 cases) or bilateral (123 cases) orchidopexy. Puri
and O’Donnell (1988) studied 142 men who underwent unilateral (119 men) or bilateral (23 men) orchidopexy at age
7 years or older and reported normal sperm density in 84% and 50% of cases, respectively. Available data
suggests that sperm counts are reduced in at least 25% of formerly unilateral and the majority of formerly bilateral
cryptorchid men, but paternity rates in the unilateral group are similar to those in control men.

Risk of Testicular Tumour:

The relative risk of malignant transformation in an undescended testis is 2.5 to 8 overall and 2 to 3 in boys
undergoing prepubertal orchidopexy, which is lower than historical estimates.Review of tumor pathology in
treated versus untreated cryptorchidism shows that seminoma is associated with persistently cryptorchid
testes (74%) and non-seminoma is present in the majority of scrotal testes (63%) (Wood and Elder, 2009).
9
Certain subgroups with undescended testis are at increased risk for TGCT, including those with
chromosomal defects and other genital anomalies (Cortes et al, 2001; Husmann, 2005). Husmann
(2005) recommends that biopsy be performed in these individuals and in boys older than 12
undergoing orchidopexy. Orchiectomy should be considered the preferred treatment of cryptorchid
testes from puberty to the age of 50. Testicular self-examination, which requires education and
counselling of the patient, remains a mainstay of testicular cancer screening.

Key Points:
Gonadal determination involves separate genetic pathways for development of testis and
ovary. SRY is a master switch in males that regulates downstream testis-determining genes.
Differentiation of gonocytes and Sertoli and Leydig cells occurs at 5 to 9 weeks’ gestation, and
the gubernaculum, the guide for testicular descent, appears at 7 weeks’ gestation.
Levels of the Leydig cell hormones testosterone and INSL3 peak at 14 to 17 weeks’ gestation
and are critical for testicular descent.
Swelling of the gubernaculum, which starts in the secondtrimester, provides space for passage
of the testis into the scrotum at 20 to 28 weeks’ gestation.
Cryptorchidism occurs in 1% to 4% of full-term male infants; both spontaneous descent (in the
first few months of life, usually by 6 months) and reascent of testes may occur.
The causes of cryptorchidism are largely unknown, but birth weight, gestational age, and
genetic and environmental risk factors likely contribute to disease risk.
The diagnosis of cryptorchidism may be acquired—that is, made in cases of apparent full
descent at birth or after spontaneous descent of a cryptorchid testis—and may be more
common in boys with retractile testes. Yearly testicular examinations are recommended.
About 80% of undescended testes are palpable and 60% to 70% are unilateral.
Many boys with nonsyndromic cryptorchidism have epididymal anomalies and a patent processus
vaginalis, and some have reduced LH and/or testosterone levels during the postnatal surge.
Orchidopexy is recommended for testes that remain undescended after 6 months of age;
hormone therapy is not recommended.
Laparoscopy is the procedure of choice, and imaging studies are rarely useful in the diagnosis
and treatment of abdominal cryptorchidism.
Sperm counts are reduced in at least 25% of formerly unilateral and the majority of formerly bilateral
cryptorchid men, but paternity rates in the unilateral group are similar to those in control men, and
spermatogonia counts may predict fertility potential in males with cryptorchidism.
TGCT risk is two to five times higher in boys with cryptorchidism, especially after pubertal orchidopexy.

Suggested Reading:
Hutson JM, Hasthorpe S. Abnormalities of testicular descent. Cell Tissue Res 2005;322:155–8.
Fowler R, Stephens FD. The role of testicular vascular anatomy in the salvage of high
undescended testes. Aust N Z J Surg 1959;29:92–106.
Josso N, Picard JY, Rey R, et al. Testicular anti-müllerian hormone: history, genetics,
regulation and clinical applications. Pediatr Endocrinol Rev 2006;3:347–58.
Penson D, Krishnaswami S, Jules A, et al. Effectiveness of hormonal and surgical therapies for
cryptorchidism: a systematic review. Pediatrics 2013;131:e1897–907.
Thorup J, McLachlan R, Cortes D, et al. What is new in cryptorchidism and hypospadias—a
critical review on the testicular dysgenesis hypothesis. J Pediatr Surg 2010;45:2074–86.
Julia Spencer Barthold, MD, and Jennifer A. Hagerty, DOEtiology, Diagnosis, and Management
of the Undescended Testis, Pg3430 InCampbell-Walsh Urology: Alan J Wein, Loui R Kavoussi,
Alan W Partin, Craig A Peters (Eds). 11th Edition. Elseviers. 2016.
Cryptorchidism. In Kelalis-King-Belman Textbook of Clinical Pediatric Urology, Fifth Edition.
Steven G. Docimo, Canning Douglas A, Khoury Antoine E (Eds), 2016
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Barteczko KJ, Jacob MI. The testicular descent in human. Origin, development and fate of the gubernaculum Hunteri,
processus vaginalis peritonei, and gonadal ligaments. Adv Anat Embryol Cell Biol 2000;156:III–X, 1–98.
Hutson JM, Hasthorpe S. Abnormalities of testicular descent. Cell Tissue Res 2005;322:155–8.
Wenzler DL, Bloom DA, Park JM. What is the rate of spontaneous testicular descent in infants with cryptorchidism? J
Urol 2004;171:849–51.
Sharpe RM, Skakkebaek NE. Testicular dysgenesis syndrome: mechanistic insights and potential new downstream effects. Fertil
Steril 2008;89: e33–8.
Cendron M, Huff DS, Keating MA, et al. Anatomical, morphological and volumetric analysis: a review of 759 cases of
testicular maldescent. J Urol 1993;149:570–3.
Cox MJ, Coplen DE, Austin PF. The incidence of disorders of sexual differentiation and chromosomal abnormalities of
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and malignancy. J Pediatr Surg 1986;21:691–6.
Puri P, O’Donnell B. Semen analysis of patients who had orchidopexy at or after seven years of age. Lancet 1988;2:1051–2.
Wood HM, Elder JS. Cryptorchidism and testicular cancer: separating fact from fiction. J Urol 2009;181:452–61.
Cortes D, Thorup JM, Visfeldt J. Cryptorchidism: aspects of fertility and neoplasms. A study including data of 1,335 consecutive
boys who underwent testicular biopsy simultaneously with surgery for cryptorchidism. Horm Res 2001;55:21–7.
Husmann DA. Cryptorchidism and its relationship to testicular neoplasia and microlithiasis. Urology 2005;66:424–6.

BREAST CANCER STAGING

-Dr Anurag Srivastava
Breast cancer is staged according to its anatomical extent by clinical, radiological and pathological
examination. Aim of staging is to help us in treatment planning, prognostication of the disease, better
understanding of the disease and communicate between oncological centers. The most commonly
used staging system is TNM staging given by American Joint Committee on Cancer which includes
three components – Tumor size (T stage), Nodal status (N stage) and Distant Metastasis (M stage);
And a grouped staging is given combining these 3 components.

7th Edition of TNM staging system

T Staging
TX Primary tumor cannot be assessed.
T0 No evidence of primary tumor.
Tis Carcinoma in situ.
Tis (DCIS) DCIS.
Tis (LCIS) LCIS.
Tis (Paget) Paget disease of the nipple NOT associated with invasive carcinoma and/or
carcinoma in situ (DCIS and/or LCIS) in the underlying breast parenchyma. Carcinomas in the breast
parenchyma associated with Paget disease are categorized based on the size and characteristics of
the parenchymal disease, although the presence of Paget disease should still be noted.
T1 Tumor ≤20 mm in greatest dimension.
T1mi Tumor ≤1 mm in greatest dimension.
T1a Tumor >1 mm but ≤5 mm in greatest dimension.
T1b Tumor >5 mm but ≤10 mm in greatest dimension.
T1c Tumor >10 mm but ≤20 mm in greatest dimension.
T2 Tumor >20 mm but ≤50 mm in greatest dimension.
T3 Tumor >50 mm in greatest dimension.
T4 Tumor of any size with direct extension to the chest wall and/or to the skin (ulceration or skin nodules).
T4a Extension to the chest wall, not including only pectoralis muscle adherence/invasion.
T4b Ulceration and/or ipsilateral satellite nodules and/or edema (including peau d'orange)
of the skin, which do not meet the criteria for inflammatory carcinoma.
T4c Both T4a and T4b
T4d Inflammatory carcinoma.

NX Regional lymph nodes cannot be assessed

N0 No regional lymph node metastases.
N1 Metastases to movable ipsilateral level I, II axillary lymph node(s).
N2
N2a Metastases in ipsilateral level I, II axillary lymph nodes fixed to one another (matted) or to
other structures.

11
 N2b Metastases only in clinically detected ipsilateral internal mammary nodes, in the absence
of clinically evident level I, II axillary lymph node metastases.
N3
N3a Metastases in ipsilateral infraclavicular lymph node(s).
N3b Metastases in ipsilateral internal mammary lymph node(s) and axillary lymph
node(s). N3c Metastases in ipsilateral supraclavicular lymph node(s)

M0: No clinical or radiographic evidence of distant metastases.

cM0(i+) : No clinical or radiographic evidence of distant metastases, but deposits of molecularly or
microscopically detected tumor cells in circulating blood, bone marrow, or other non-regional nodal
tissue that are ≤0.2 mm in a patient without symptoms or signs of metastases.
M1: Distant detectable metastases as determined by classic clinical and radiographic means and/or
histologically proven >0.2 mm

Limitations
It was modeled based on Halstedian theory of sequential spread of cancer from breast to lymph nodes to systemic
circulation. However, there has been a paradigm shift from anatomical model to biological aggressiveness, which
the TNM staging fails to incorporate. Treatment planning has drastically changed since the introduction of TNM.
Currently, Breast Conservation Surgery (BCS) is the norm. To plan a patient for BCS, we need to know the tumor
breast ratio, location of tumor, position of tumor with respect to nipple, multii-focality
multi-centricity, co-existing extensive in-situ disease. None of these are included in the current TNM
staging. With increase in use of Skin Sparing Mastectomy and Nipple Sparing Mastectomy, the data of
position of tumor with respect to skin and nipple, multicentricity, extensive in situ disease in the
staging system can be resourceful.
In-situ disease is not classified based on its size. But the size of tumor, tumor breast ratio, distance from skin and
nipple are all important factors to decide about the surgical options, Axillary node assessment by sentinel biopsy
and adjuvant therapy. Large In-situ tumors have chance of associated invasive component, which can have nodal
spread. Sentinel biopsy cannot be performed after tumor excision. Small, low grade in-situ tumors need not be
treated with adjuvant therapy. But this information is not included in TNM staging.
T staging includes wide range of sizes. The prognosis is different for a tumor with size 2cm and 5cm. But
according to the current TNM both fall in the same category. Clinical Nodal staging does not include number of
nodes, though it is included in the pathological staging. Prognosis varies with number of nodes involved. Thus,
heterogeneous groups with varied prognosis are included within a category. TNM has limitations in planning
adjuvant therapy also. Hormone receptor statuses are not included, based on which adjuvant chemotherapy and
endocrine therapy are planned. Though histological grading and types are separately mentioned below the
staging, it is not incorporated into it. Recent advances include molecular typing of tumors based on which
decision of adjuvant therapy is made. Thus, it is doubtful if TNM staging fulfills its objective of aiding in planning
treatment, adjuvant therapy, understanding the disease and easy communication. Molecular classification can
give us better perception towards prognosis and adjuvant therapy.
Molecular Classification of Breast Cancer: Based on Gene-profiling

Subtypes ER Her2 Neu KI67

Luminal A Group ER positive Her2 negative Low

Luminal B Group ER positive Her2 positive High

HER2/neu- ER negative Her2 positive High

Overexpressive Group

Basal-like ER negative Her2 negative High

(Express breast PR negative
epithelial cell markers-
basal cytokeratin
CK5/6; EGFR +/-;
CKIT +/-

Claudin-low ER negative Her2 negative High

12
 E ARLY BREAST CANCER
-Dr P.N.Agarwal
-Dr Bhuwan Kumar
Early breast cancer is defined by stage , IIA or IIB (T2N1, T3N0)i. This includes patient with T1 (≤20mm) or T2
(≥20mm but ≤50mm) and cN1(metastasis to movable ipsilateral level I, II axillary lymph no de) or cN1mi (micro
metastasis- approx. 200cells, larger than 0.2 mm, but none larger than 2.0mm) or T3(>50mm )ii.
The recommended workup of localized i nvasive breast cancer includesiii: (NCCN Guidelines))
History and physical examinatio n
Bilateral diagnostic mammography
Breast ultrasonography, if neces sary
Tissue diagnosis and receptor s atus (ER, PR and HER2-receptor)
Complete blood count,platelet c ount, LFTs and ALP level
Chest radiograph
Bone scan is indicated if localize d bone pain or elevated ALP
Abdominal +/- Pelvic diagnostic CECT if abnormal LFT, abdominal symptoms or abnormal
physical examination
Chest diagnostic CECT if pulmonary symptoms
present MRI under special circumstances
Clinically positive axillary nodes and occult primary breast
cancer Paget’s diseaseof nipple with breast primary not identified
Evaluation of response to preoperative systemic
therapy Assess the potential for BCS
PET scan can be used for stagin g but not recommended routinely.
High false - rate in detection of lesions that are <1 cm and/or low gr
ade Low sensitivity for detection of axillary nodal metastasis.
Low probability of these patients having detectable metastatic disease.
In a study by Avril et aliv, wh ile PET imaging detected 92% of pT2 lesions, only 68% of pT1
lesions (<2 cm) were detected.
Groheux et alv reported sta ge modification due to N3 disease and/or distant metastases
detection in 16.1% of patients with clin ical stage 2b disease.
Thus, FDG PET can serve as a one-stop shopping imaging technique for patients who would
benefit from whole-body staging, such as in clinical stage 2b-or-above disease, or for patients
with clinical suspicion of distant d iseasevi.

Surgical management
1. BCS + SLN biopsy +RT With adjuvant systemic therapy
2. MRM
Several randomized trials document that breast conserving therapy is equivalent to mastecto my with
respect to survival as primary breast local treatment for the majority of women with stage I and stage II.
NSABP-06 TRIAL compared tot al mastectomy to lumpectomy with or without RT in the treatment of
women with stage I and II breas cancer. After 5- and 8-year follow-up periods, DFS, distant disease-
free and OS rates were similar. The in-breast recurrence rate was substantially high er in the
lumpectomy alone group (39.2% ) compared with the lumpectomy plus adjuvant radi ation
therapy group (14.3).
The EBCTCG (Early Breast Canc er Trialists' Collaborative Group) did meta-analysis on Breast conservation
performed with or without radiation therapy. Radiotherapy reduced the 10-y r. risk of any (loco regional or
distant) first recurrence from 35% to 19.3 %. At 15 years of follow-up, the abbsolute reduction in mortality with
the use of RT after lumpe ctomy was 5.1% in node-negative patients and 7. 1% in node-positive patients.
Radiation not only improves local control but also has an impact on survival. vii

13
BCT (Breast conserving therapy)
A major goal of BCT is the preservation of a cosmetically acceptable breast without compromise of
local tumor control

Contraindications of BCS
ABSOLUTE
Pregnancy
Diffuse suspicious or malignant appearing micro calcifications
Widespread disease that cannot be incorporated by local excision through single
incision that achieves negative margins with a satisfactory cosmetic result.
Positive pathologic margins

RELATIVE
Active connective tissue disease involving skin (scleroderma and lupus)
Tumor >5 cm
Focally positive margin
Women with a known or suspected genetic predisposition to breast cancer
Centrally located tumor
After surgical resection ‘no ink on tumor’ has been accepted as the standard for negative surgical
margins for invasive cancer

WHOLE BREAST RADIATION

If the pathological report has negative margin, patient is planned for WBRT with tumor bed boost.
Breast tissue in entirety is included, the whole breast should receive a dose of 46-50 Gy in 23 -25
fractions or 40-42.5 Gy in 15-16 fractions. All dose schedules are given 5 days per week. A boost to the
tumor bed is recommended in patients at higher risk for recurrence such as age <50, high grade
disease or patients with focally positive margins. (10-16 Gy in 4-8 fractions).
Patient can also be advised APBI (Accelerated partial breast irradiation) which involves a course of
34Gy in 10 fractions delivered twice per day with brachytherapy or 38.5Gy in 10 fractions delivered
twice per day with externalbeam photon therapy is prescribed to tumor bed.
ASTRO guidelines describe patients” Suitable” for APBI to be, women 60 years of age or older with a
unifocal, T1, ER-positive tumor with no lympho-vascular invasion, and margins of at least 2 mm.

SURGICAL AXILLARY STAGING

In clinically negative axilla SLNB is recommended for patients with clinical stage I, II and IIIA.
The combination of intraoperative gamma probe detection of radioactive colloid and intraoperative
visualization of blue dye (isosulfan blue dye or methylene blue) is more accurate for identification of
SLNs than the use of either agent alone.

Level I and II axillary dissection is recommended when

Patient have clinically positive nodes that are confirmed
by FNA Sentinel nodes not identified
ALN should be extended to include Level III nodes if I & II are bulky.
ACOSOG Z-0011 trial addressed the need for completion ALND for patients with EBC that were clinically node
& ≤ 2 positive SLNs.All patients underwent breast irradiation. At a median follow-up of 6.3 years,
there were no significant differences in survival or loco-regional recurrence between the SLND plus
ALND group versus the SLND alone group. The five-year OS, five-year DFS and recurrence rates in the
ipsilateral axilla were all similar between the two arms.
MASTECTOMY is indicated for patients who are not candidates for lumpectomy and those who choose
to undergo this procedure over lumpectomy.
Post mastectomy radiation therapy is considered only for selected patients with stage II disease, such
as patients with extracapsular extension, lymphovascular invasion, age 40 years or younger, close
surgical margins, or a nodal positivity ratio (ratio of positive nodes to total nodes examined) of 20% or
greater and patients who have undergone less than a standard level I or II axillary dissection.viii

ADJUVANT CHEMOTHERAPY
Systemic therapy is used to treat and prevent recurrence of microscopic metastatic
breast cancer. Indications
HER 2 positive - any tumor>0.5 cm and /or Node positive
HER 2 negative & ER negative- tumor size >1cm, nodepositive; can be considered in tumors
0.5 -1 cm if there is Lympho-vascular invasion and high-grade features.
HER 2 negative and ER positive- node positive, high oncotype Dx recurrence score, can be
considered if high risk features present.
14
Patient with hormone receptor positive cancer should receive should receive at least 5 years of either
Tamoxifen or an Aromatase inhibitor.
Tumors overexpressing Her2/neu also require treatment with Adjuvant Trastuzumab. The NCCN
guidelines recommend a total of 12 months of Adjuvant trastuzumab as standard of care.

MULTIPARAMETER GENE EXPRESSION ANALYSIS

Multigene assays, such as the 21-gene recurrence score assay (Oncotype DX, Breast Cancer
Assay),Mamma Print, PAM-50 ROR score&EndoPredict have been developed in an attempt to identify a
specific molecular phenotype of a tumor in an individual patient.Assessing the expression of multiple
genes in a tumor sample may provide useful information about tumor behavior.

ONCOTYPE DX IS genomic test that predicts

likelihood of cancer recurrence,
It can help to guide decision making regarding chemotherapy in patients with
node -, ER+ breast cancer
benefit from chemotherapy, survival; thus, individualizing treatment.
This assay is performed using formalin fixed paraffin embedded tumor tissue. Itutilizes PCR
technique and measure RNA transcripts ofa panel ofbreast cancer associated genes.
It evaluates activity of 21 genes
Score ranges from 0 -100.
>31 high Risk,18-31 intermediate risk, <18 low risk
Higher the score, greater is risk of recurrence.
Patient with high score get significant benefit from Adjuvant chemotherapy.
◦
Mammaprint
Is based on the Amsterdam 70 gene breast cancer gene signature and
usesformalin fixed paraffin embedded or fresh tissue for microarray analysis.
It can be used in cancer patients regardless of ER or HER2 status.
This classifies patient as being at either high or low risk of breast cancer recurrence.

DECISION MAKING FOR SYSTEMIC THERAPY

FOLLOW UP
History and examination 1-4 times per year as clinically appropriate for 5 years, then
annually Educate, monitor and refer for lymphedema management
Mammography every 12 months
Lab investigations or imaging to look for recurrence/metastasis done if clinical symptoms and
signs present.
On tamoxifen,gynecologic assessment every 12 month if uterus present
On aromatase inhibitor, bone mineral density is done periodically
15
REFERENCES
1HuntKK,Robertson JFR,Bland KI.The Breast.In :Brunicardi FC.Schwartz Principles Of surgery Ed 10:McGraw Hill;2015 p538
1Hortobagyi GN, Connolly JL, D’Orsi CJ et al.Breast. In: Mahul B.Amin.AJCC Cancer Staging Manual Ed 8:Springer;2017 p619
1
National comprehensive cancer network.The complete library of NCCN clinical practice guidelines in oncology.Breast Cancer,version
2.2017.
1Avril N, Rose CA, Schelling M, et al. Breast imaging with positron emission tomography and fluorine-18
fluorodeoxyglucose:use and limitations. J Clin Oncol. 2000;18(20):3495-3502
1.Groheux D, Hindie E, Delord M, et al. Prognostic impact of (18)FDG-PET-CT findings in clinical stage III and IIB breast
cancer. J Natl Cancer Inst. 2012;104(24):1879-1887
Schuster, David M. "Clinical Utility of PET Scanning in Breast Cancer Management." American Journal of
Hematology/Oncology® 11.6 (2015).
Hunt KK,Mittendorf EA.Diseases of Breast.Sabiston Textbook of Surgery.Ed 20:Elsevier;2017 p845
Hunt KK,Mittendorf EA.Diseases of Breast.Sabiston Textbook of Surgery.Ed20:Elsevier;2017 p854

LOCALLY ADVANCED BREAST CANCER

Dr. Geeta Kadayaprath

Locally advanced breast cancer (LABC) continues to be the major proportion of breast cancer patients in
India and is a challenging management problem around the world (1). Most of the developing world
including India finds that LABC constitutes 40% to 60% of newly found malignant breast neoplasms (2, 3,4).
About 300,000 to 450,000 new cases of LABC are diagnosed around the world every year. Historically,
outcomes in LABC have been poor and though, neoadjuvant chemotherapy was introduced with the intent
to improve tumor resectability and overall survival, the goal of overall survival was not realized. However,
other clinically important outcomes like down staging and feasibility of BCS were observed. Now NACT has
extended to beyond classically unresectable tumors to smaller tumors with adverse biology like Triple
negative breast cancers and Her-2-neu positive tumors.
LABC includes large primary tumors (>5 cm, T3 in the American Joint Committee on Cancer [AJCC]
cancerstaging system), tumors of any size associated with skin or chest wall involvement (T4), tumors with
fixed ormatted axillary lymph nodes (N2), and those with involvement of the ipsilateral infraclavicular,
internal mammary with axillary nodes andsupraclavicular lymph nodes (N3) (5). Tumor size breast ratio can
be a premise for treating 3-5cm tumors in a small breast with a multimodality approach.

DIAGNOSIS AND STAGING

Clinical Examination
A complete physical examination, with accurate documentation of all palpable abnormalities of the
affected breast, axilla and supraclavicular fossa
Careful examination of the contralateral breast, axilla and the
supraclavicular fossa Diagnostic tests
Bilateral mammogram must be done routinely to assess the primary tumor and to rule out
thepresence of synchronous bilateral cancer or contralateral metastases.

Ultrasound of the breast complements the mammogram to better delineate tumor dimensions and to
detail any regional lymph node involvement.

MR mammogram is a useful modality in tumors not well defined on conventional mammogram and
ultrasound, particularly invasive lobular carcinoma and inflammatory cancer.
It is also used for-
Baseline assessment of the extent of tumor involvement and placement of markers prior
to NACT Determining additional foci of cancer
To assess response to therapy after NACT

Histological Diagnosis
A core needle biopsy must be done to establish a histologic diagnosis and to determine estrogen
(ER) and progesterone-receptor (PR) status, Her-2-neuand Ki-67also.
However, incisional biopsies are recommended when inflammatory breast cancer is suspected.

Staging Investigations
Biochemical survey,
CECT chest and
abdomen Bone Scan
PET CT is being used increasingly in LABC to rule out
metastases Tumour markers
16
TREATMENT STRATEGIES
Treatment of all breast cancers requires a multidisciplinary approach and more so in LABC. After careful
deliberations with the radiologist, pathologist, and surgical, radiation, andmedical oncologists and going over all
the data available, an optimal treatment plan should be drawn up. A careful discussion with the patient is
important so that the entire treatment is thought through even before it starts. If the patient is desirous of breast
conservation and seems to be a suitable candidate after downstaging, then a clip should be inserted into the
tumor at the start or after two cycles of chemotherapy. The usual sequence of treatment in LABC is anterior
chemotherapy followed by surgery followed by radiation and then hormonal treatment if required.

Neoadjuvant Chemotherapy
Anthracycline based combination chemotherapy regimens are the mainstay of treatment of locally advanced
breast cancer. Administration of combination chemotherapy produces major reductions in tumor volume in 60% to
90% of patients. Tumor reduction happensconsistently in both the primary tumor and the enlarged regional lymph
nodes(6-19)Response in the primary tumor and noresponse in the regional lymph nodes, or vice versa is known
but they are uncommon (20,21,22). Clinical complete responses happen in 10% to 20% of patients with LABC
treated with anthracycline-containing combination chemotherapy regimens (8, 11, 16, 17, 23). Addition of taxanes
results in better response especially complete response rates, when used sequentially. Taxanes with other drugs
are reported to have marked antitumor activity, with overallresponse rates in the 80% to 95% range. Unfortunately,
the reported clinical and pathologic completeremission rates are only marginally higher than those reported with
older combinations.Other drugs under investigation in the neoadjuvant setting are gemcitabine, vinorelbine,
platinum analogs, ixabepilone, trastuzumab, bevacizumab, and Lapatinib. Themedian number of cycles required to
achieve a partial remission was reported to be four, and for acomplete remission, five (22). Pathological complete
remission is more often seen in ER negative cancers and uncommonlyin ER+ tumors and is rare after neoadjuvant
endocrine therapy. In ERBB2-amplified or overexpressing breast cancers, addition of trastuzumab to
chemotherapy produces pathologicalcomplete remission rates ranging from 20% to 70% (24).

Neoadjuvant Endocrine Therapy

Limited information is available about neoadjuvant endocrine therapy (25). The initial trials used
Tamoxifen in ER+ patients who were older or had comorbidities thatprecluded chemotherapy
(26,27,28). Aromatase inhibitors have also been used for neoadjuvant endocrine treatment, particularly
Letrozole. There was marked reduction in tumor volume in 40% to 60% of patients. Close monitoring is
required to identify those who progress on neoadjuvant endocrine therapy and appropriatesurgery or
RT should follow endocrine therapy for optimal local and systemic control (29,30).Greater antitumor
efficacy has been observed with aromatase inhibitors compared to Tamoxifen (31). In general,
response to neoadjuvant endocrine therapy occurs in 35% to 50% of patients with hormone receptor–
positive breast cancer, but fewer than 5% achieve pathological complete remission. Response rates to
neoadjuvant endocrine therapies in this setting are lower than response rates to anthracycline- or
taxanes based chemotherapy in unselected patients with LABC (30) Early progression is observed
more frequently after neoadjuvant endocrine therapy(12% to 17%) than after NACT (5% to 10%) (32).

Assessment of Response
Complete clinical complete remission requires that no residual disease be present by physical examination
and by imaging (mammography or ultrasound) in the breast or regional lymph nodes (16). Ironically, only
half to two thirds of patients thought to have a clinical complete remission are found to have a pathologic
complete response (i.e., no residual disease) (8, 11, 16, 22, 33). Clinical measurements of breast masses are
often inaccurate, and can have significant variation between examiners (34).
Therefore, imaging methods are often used to more reliably documentextent of disease (34, 35, 36),
especially if breast conservation surgery is contemplated after NACT. Clinical examination combined
with either mammography orultrasound gives measurements that are closely matched by
histopathology. (36). MRI is also frequently used todetermine extent of disease, especially in the
preoperative setting to help define optimal surgical therapy (37).
Achieving a histologically documented complete remission is a surrogate marker for markedly
improved long-term prognosis in patients with Triple negative breast cancers and Her-2-neu+ breast
cancers who have received Trastuzumab in their neoadjuvant regime (10, 38). Furthermore, these
patients are often excellent candidates for breast-conserving strategies. In recent years, PET has been
evaluated to assess response.Several authors have reported thatnot only does PET identifymetastatic
lesions not found by other imaging modalities, butis also a verysensitive tool to monitor the functional
status of the tumor. Thus, changes in PET imaging, such as markedreductions in standardized uptake
values, are under evaluation for early determination of response to neoadjuvant systemic therapy (39).

Considerations for Imaging

A common denominator underlying clinical decisions about appropriate surgical treatment for LABC
is theimportance of accurate imaging.

17
It is important at initial presentation to estimate tumor size and determineif the patient is a good
candidatefor NACT. During and after NACT, imaging of the primary tumor and the axillary lymph nodes
is used toassess treatment response and aid in surgical planning.

Standard Imaging Modalities after Neoadjuvant Chemotherapy

Mammography and ultrasound have been shown to offer accurate predictions of pathologic tumor size inpatients
with small invasive ductal carcinomas without an extensive intraductal component, provided the patients have not
received NACT (40). In patients who have received NACT, however, there have been widely disparate reports on
the accuracy of these imaging approaches forpredicting residual pathologic tumor size.

Magnetic Resonance Imaging for the Assessment of Neoadjuvant Chemotherapy Response

MRI is a newer modality in the assessment of extent of breast cancer locally and its accuracy is quite
variable. However, MRI appears toallow a more precise estimation of residual tumor than
mammography or ultrasound (41, 42, 43). Although MRI is very sensitive, it may not be able to identify
small foci of disease and in situ disease as well. However, MRI may be used to assess the suitability of
a patient for breast conservation surgery.

Approaches to Local Therapy

For patients with operable (stage IIIA) LABC, a modified radical mastectomy, followed by systemic
adjuvanttherapy, represents an effective treatment option (44). Selected patients with small T4 tumors
may alsobe approached with surgery as their initial treatment modality (45). However, the
administration of NACTas the first modality of treatment, before surgical therapy is instituted, is
favored by most expert groupsfor the management of stage III and most large stage II breast cancers,
despite the fact that no survival benefit has been documented in patients undergoing surgery first or
chemotherapy first.Surgical therapy- There are no RCTs comparing modified radical mastectomy with
breast conservation surgery (BCS) in patients with LABC unlike in early breast cancer. Large LABCs
are best treated with modified radical mastectomy.Guidelines from American College of Radiology,
NCCN and the Consensus Conference on neoadjuvant chemotherapy in carcinoma of the breast
indicate that breast-conserving therapy is appropriate for some patients withlocally advanced breast
cancers, which include small N2 or N3 tumors with nodal response or large T3N0 or T3N1 with good
response (10,46,47,48,49,50). BCS is not recommended for patients with inflammatory breast cancer.

Sentinel Node Biopsy before Preoperative Chemotherapy

SNB is an established method for staging the axilla in early breast cancer but its role before or after
NACT is still contentious and there is not enough data to support either approach. Whatever limited
data is available suggests higher sentinel lymph node identification rates and lower false negative
rates when SLNB is performed prior to NACT. Before NACT, the identification rate was 98-99% and
after NACT was 93%in patients with clinically node negative disease and 88% overall. (51, 52, 53) For
now, Axillary dissection is the standard of care for axillary staging in LABC.

Considerations for Breast-Conserving Surgery

The use of NACT has become standard management for patients with LABC, in part because it frequently
reduces the size of the primary tumor enough to allow previously inoperable tumors to become operable.

Selection criteria for breast conservation after NACT

Complete resolution of skin edema [peau
d'orange] Adequate reduction in thetumor size
No extensive intramammary lymphatic invasion
Absence of extensive suspicious
microcalcifications No evidence of multicentricity

The local recurrence rate and 10-year overallsurvival after breast-conserving therapy are almost equivalent
to those seen in early stage breast cancer patients (54).Since 30% of patients undergoing NACT will achieve
complete clinical response, it is important to localize the tumor site accurately before start of NACT as it
may be impossible to do so at the time of surgery (55). In addition, nearly two- thirds ofpatients with a
clinical complete response will prove to have residual tumor on final pathology, so it iscritically important to
be able to precisely localize and remove the tumor with clean margins (55). This can be accomplished by the
placement of a metallic marker under ultrasound or mammographic or MR guidance in the tumor during the
course of the chemotherapy. The best time to do so is when the tumor has shrunk to less than 2cms in size
(56,57). If it is placed before the initiation of NACT, the tumor may shrinkeccentrically, leaving the marker on
the edge of the residual tumor, rather than in the epicenter. A Cookcoil (Cook, Inc., Bloomington, Indiana) is
sometimes used, which is a small platinum marker with a coileddiameter of 2 mm and an extended length of
1 cm. The marker is inserted with a 15 gauge 8-cm long needle and a blunt stylet under ultrasound
guidance. Alternatively onemay use stereotactic clips, which are much smaller in size.

18
Mammography is performed immediately aftermarker implantation to precisely document the position
of the marker in relation to the tumor.Just prior to surgery, the radiologist under ultrasound or
mammographic guidance, to indicate the location of the marker, inserts a J- wire. Surgical excision
does not attempt to remove thepre-chemotherapy volume of tumor but to remove any residual lesion
with 1 cm of clearmargins or, if there is no detectable residual lesion, a 2-cmspecimen with the metal
coil in the center is removed. When the specimen is removed, the orientation is designatedprior to
leaving surgery with the help of different colors of ink or silk thread of various sizes viz. long –lateral,
medium-medial, short-superior etc. A specimen radiograph is taken to verify the presence ofthe
marker within the excised specimen and then sent to the pathologist for assessment of margins.

Considerations for Reconstructive Surgery

Current reconstructive techniques using autologoustissue flaps offer excellent cosmetic results
without compromising long-term outcomes in patients undergoing mastectomy after NACT. It is
possible to do an immediate breast reconstruction at the time of mastectomy, but a careful discussion
between the physician and the patient is mandatory.Patients with LABC are known to have a high risk
of chest wall recurrences following mastectomy alone(58). They are all likely to undergo postoperative
radiation therapy, which can compromise the cosmetic outcome of the reconstruction. Besides, the
reconstructed breast mound can interfere with the treatment delivery as well.

Radiotherapy after surgery

For all patients of LABC, radiotherapy is mandatory after mastectomy or BCS. The EBCTG meta-
analyses found that post mastectomy RT significantly reduced the 5 year and 10 year recurrence risk
in patients with positive nodes or patients who received systemic therapy.It also showed that post
mastectomy RT significantly improved 20 year breast cancer mortality across all subgroups. It is also
recommended that patients with LABC receive loco regional radiation encompassing the breast or
chest wall and local node bearing areas after BCS or mastectomy. (59)

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Detection Demonstration Project. CA Cancer J Clin 1987;37:258–290.
Zeichner GI, Mohar BA, Ramirez UMT. Epidemiologia del Cancer de Mama en el InstitutoNacionalde Cancerologia (1989–
1990).Cancerologia 1993;39:1825–1830.
Moisa FC, Lopez J, Raymundo C. Epidemiologia del carcinoma del senomamario en Latino America.Cancerologia 1989;35:810–814.
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endocrine therapy in locally advanced breast carcinoma. Am J ClinOncol 1990;13:226–232.
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patients homogeneously treated with a combined modality approach. Eur JCancer 1995;31A:1428–1433.

Kemeny F, Vadrot J, d'Hubert E, et al. Evaluation histologique e radioclinique de l'effet de la

chemotherapie premiere sur les cancers non inflammatoires du sein. Cahiers Cancer 1991;3:705–714.
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Preece PE, Wood RA, Mackie CR, et al. Tamoxifen as initial sole treatment of localised breastcancer in elderly women: a pilot
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with tamoxifen and optimal surgery with tamoxifen alone. Br J Surg1991;78:591–594.
Kenny FS, Robertson JFR, Ellis IO, et al. Long-term follow-up of elderly patients randomized toprimary tamoxifen or wedge
mastectomy as initial therapy for operable breast cancer. Breast 1998;7:335–339.
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positive, estrogen receptor-positive primary breast cancer: evidence from a phase III randomized trial. J ClinOncol 2001;19:3808–3816.
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chemotherapy response in breast cancer. Israel Med Assoc J 2006;8:342–346.
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 METASTATIC BREAST CANCER

-Dr. Kumkum Singh

Breast cancer is on rise today and has become number one cancer in females. A disease initially thought to be
affecting patients with high socioeconomic status is now equally seen in urban and rural population. In India,
majority of patients present in advanced stage. It is common to see patients with fungating masses and large
ulcers over breast. Most of these patients are metastatic already at their first presentation to a surgeon.
MBC is also referred as – Advanced breast cancer, Stage 1V B cancer.
Per se by definition tumour which has spread beyond breast, axillary lymph nodes and chest wall is
labelled as MBC.
Common sites for metastasis include- Bones (70%), Liver (20-30%), Lungs (10-15%), and Brain (2-5%).
Metastasis may present several years after surgery of primary tumour or may be present at the first
presentation. Metastatic cells differ from primary cells in properties such as receptor status. These
cells develop resistance to various previous treatment modalities. MBC is responsible for 90% deaths
in cancer breast. MBC can be treated but cannot be cured.

ENVIRONMENTAL BARRIERS IN A METASTATIC EVENT:

Physical – Basement membrane
Chemical-reactive oxygenation, hypoxia, low pH
Biological- immune surveillance, inhibitory cytokines, regulatory ECM peptide.
PATHOPHSIOLOGY
Initial theories of spread of cancer included the Halsted’s hypothesis (local), Fishers Hypothesis
(systemic disease) and Spectrum theory of Helman
RECENT CONCEPT - SEED & SOIL HYPOTHESIS
Primary tumour-- invasion of BM— LVI – cells get arrested in microvasculature of secondary site—
extravasations of cells—invade BM of target tissue – proliferation and formation of micro metastasis---
metastasis.
INVESTIGATIONS/ METASTATIC WORKUP
Whole body scan.
MRI/ PET CT
CT CHEST & ABDOMEN.
USG abdomen and pelvis.
Biopsy of lesion – very important ( biomarkers may differ in primary and secondary deposits)
LFT, Pleural fluid analysis, Ascitic fluid analysis.
Study of CTC and ctDNA

Common in lumbar vertebra, femur, pelvis, ribs, skull

Present as severe backache, bony pain and tenderness, spinal compression, paraplegia,
pathological fractures.
Rx – Bisphosphonates IV (Zolendronic acid-4mg,Pamidronate-
90mg) RT
Internal fixation, spinal decompression, laminectomy.
ORAL Calcium and Vitamin D3 supplements
Monoclonal Antibody- Denosumab 120mg can be given every 4 weeks.

Pain chest, respiratory distress,

breathlessness. CXR- Pleural effusion and
deposits(canon ball) CT scan
Pleural fluid examination for malignant
cells. Rx - repeated aspiration
ICD
Pleurodesis (talc, tetracycline, mitoxantrone).
Local CATUMAXOMAB has been tried
VATS or conventional resection for lung deposits
LIVER METASTASIS
Anorexia, jaundice, ascites, nodular liver
Diagnostic aspiration, USG, CECT
abdomen. Rx- single metastasis- surgery
>1 mets in 1 lobe and amenable to surgery-operate
Multiple deposits both lobes – Regional CT & RT, HA embolisation, RFA

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BRAIN METASTASIS
Intense headache, convulsions, visual
disturbances. CT Scan brain
Rx- RT, Gamma Knife.

Main stay of treatment is aggressive chemotherapy.

More useful in hormone negative tumours.
Hormone positive tumours not responding to ET
Patients with symptomatic visceral metastasis.
BASED ON 3 VARIABLES
Extent, pattern and aggression at first presentation.
Menopausal Status.
Receptor Status.
Useful in both ER + and ER- tumours
Factors guiding drugs include co morbid conditions, life threatening events, response to previous
chemotherapy, Liver status, affordability and patient’s choice.
ASCO GUIDELINES
Sequential single agent chemotherapy preferred.
Combination CT if life threatening progressive disease present.
CT mainstay of treatment irrespective of hormone status.
More useful in hormone negative tumour.
TAXANES - very active
AMBRAXANE- for pts who relapsed within 6 months of adjuvant CT or failed to respond to CT.(higher
response rate than Paclitaxel).
VINORELBINE & ERIBULINE- also newer drugs for metastatic cancer (mitotic spindle
inhibitor) BEVACIZUMAB+ PACLITAXEL– PFS improved but not OS
SINGLE AGENTS - Anthracyclines (Adriamycin & epirubicin), taxanes, anti-metabolites, platinum salts,
mitotic spindle inhibitors, cyclophosphamide.
COMBINATION REGIMES - CAF, CEF, AC, EC, GT, PACLITAXEL AND BEVACIZUMAB,
CMF TARGETTED THERAPY
HERCEPTIN – TRASTUZUMAB (FISH+ / 3+IHC)
Lapatinib –for pts progressing on herceptin (targets both her2 and EGFR tyrosine kinase)
Pertuzumab - monoclonal antibody
NEWER DRUG KADCYLA (Approved 2013).This antibody drug conjugate targets only cancer cells -
useful in Her2 positive cases- minimal side effects.
ENDOCRINE THERAPY:Depends on receptor and menopausal status.
PREMENOPAUSAL PATIENTS

amoxifen (selective ER modulator)

varian ablation- LHRH analogues, Oophrectomy, Androgens

POST MENOPAUSAL PATIENTS
Aromatase inhibitors- Non-steroidal- (Anastrazole and Letrozole) and Steroidal (Exemestane).
ER modulator- Tamoxifen
Anti-estrogen- Fulvestrant

Nanotherapies- targeting of cancer cells only

Chlorotoxin- Iron oxide nanoparticles coated with nanoparticles of 20 molecules of
Chlorotoxin-targeted to brain metastatic cancer cells
Antibodies to herceptin- coated on gold nanoparticles.

Limited role.
Removal of primary tumour definitely decreases tumour burden.
Indicated in ulcerated and fungating lesions with bleeding.
RADIOTHERAPY.
All metastatic lesions in bone and brain treated
with RT CIRCULATING TUMOUR CELLS
These are cells that have shed from a primary tumour into vasculature or lymphatics and are carried
into the circulation in the body. CTCs constitute seed for subsequent metastasis in vital distant
organs. First observed by Australian pathologist Thomas Ashworth in 1869.
Later in mid 1990s sensitive magnetic separation technology employing Ferrofish (colloidal magnetic
nano particles) & high grade magnetic separators technology indicated that very small tumours
shedding cells at <1.0/day result in detectable cells in blood.

22
Modern cancer research has demonstrated role of CTC in metastasis. A high level of heterogeneity is
seen at single cell level for both protein expression and localisation and CTCs reflected both the
primary biopsy and changes seen in metastatic disease.
LIQUID BIOPSY
Tissue biopsy is invasive, cannot be used repeatedly and is ineffective in understanding metastatic risk,
disease progression and treatment effectiveness. CTCs should be considered as liquid biopsy which
reveals metastasis in action providing live information about patient disease status. Since CTC examination
is blood based test it is easy to procure, safe and multiple samples can be taken over time.
TYPES OF CTCS
Traditional CTC (cytokeratin positive)
Cytokeratin negative CTC
Apoptic CTC
Small CTCs (cytokeratin positive + CD45-)
CTC clusters
Cell search System
FDA cleared methodology for isolating and enumerating CTC.
Presence of CTC is strong prognostic factor of OS in patients with Metastatic breast, colorectal or
prostate cancer.
CIRCULATING TUMOUR DNA
Dying cancer cells release small pieces of their DNA into blood stream known as “Cell free
circulating tumour DNA” (ctDNA).
The concentration of ctDNA increase as stage progresses. 47%in stage 1 and 55, 69 and 82 %
in stage 2, 3, and 4 respectively.
Patients who have low levels live longer.
Also evaluated as way of monitoring tumour progression and testing response to drug therapies.
A drug which gave good response in primary treatment may not respond in metastatic setup because
of the new mutations which may occur in metastatic deposits so change of therapy is required.

SENTINEL LYMPH NODE BIOPSY

-Dr. Ishan Mohan

Surgical resection is the mainstay of curative treatment for majority of solid organ malignancies. In majority of
case this entails resection of the primary tumor with wide margins and clearance of the draining lymph nodes
(regional lymphadenectomy) Eg- axillary clearance for breast cancer, neck dissection for oral SCC etc.
Regional lymphadenectomy provides both therapeutic value, by the removal of disease harbouring
nodes as well as prognostic value . eg- axillary nodal status is the single most important prognostic
marker for breast cancer and the gold standard for assessing axillary LN status is axillary clearance.
Elective Neck dissection in clinically N0 oral SCC has been shown to provide a significant survival
benefit as compared to observation alone in a landmark study by Tata Memorial Hospital (1).
While regional lymphadenectomy definitely provides the above benefits, it also adds significant morbidity to
the overall surgical procedure in a large majority of cases. E.g.- axillary clearance is associated with long
term sequelae of lymphedema, shoulder dysfunction etc. In a clinically N0 case of breast cancer who
undergo standard axillary clearance as part of radical surgery, only 30% will be found to harbour LN
metastases. Thus 70 % of such patients will bear unnecessary side effects. Groin node dissection for lower
limb melanomas or penile cancer carries the significant morbidity of lymphedema.
As the practice of surgical oncology has evolved, attempts have been made to find less invasive
methods of assessing the regional lymph nodes and thus restrict the procedure of comprehensive
regional nodal clearance to those at highest risk of harbouring disease. The most successful of these
attempts has been the evolution of the procedure of Sentinel lymph node biopsy (SNB).
CONCEPT OF SENTINEL LYMPH NODE BIOPSY
The concept of sentinel node biopsy was first given by Cabanas for penile cancer in the 1970s (2).
Subsequently Morton utilized it for malignant melanoma (3).
A sentinel lymph node is defined as the first lymph node to which cancer cells are most likely to spread
from a primary tumor. The sentinel node status is a marker for the rest of the loco regional lymph nodes.
SNB is a procedure in which the sentinel lymph node is identified, removed, and examined to determine
whether cancer cells are present. If the sentinel node is negative then it indicates that the cancer has not
spread to the regional nodes and comprehensive lymphadenectomy is not required. A positive sentinel
lymph node indicates spread of the cancer to regional nodes and hence requires standard nodal clearance.

23
TECHNIQUE OF SENTINEL LYMPHNODE BIOPSY
Based on the principles of lymphatic drainage.
A surgeon injects a radioisotope (Tc 99 sulphur colloid / Tc 99 colloidal albumin), a blue dye
(isosulfan blue/ methylene blue), or both near the tumor to locate the position of the sentinel
lymph node.
The surgeon then uses a gamma probe that detects radioactivity to find the sentinel node or
looks for lymph nodes that are stained with the blue dye
Once the sentinel lymph node is located, a small incision (about 1/2 inch) is made in the
overlying skin and the node is removed.
The sentinel node then undergoes histopathologic examination
CURRENT STATUS OF SENTINEL NODE BIOPSY
SNB is now the standard of care for management of N0 breast cancer and malignant melanomas. It
is experimental as of now for head and neck cancers, colorectal cancers, gastric cancers etc

SNB FOR BREAST CANCER

Giuliano and Krag first reported on SLNB in breast cancer using blue dye and radioisotope,
respectively, in the mid 1990s (4, 5)
NSABP B – 32 and the Milan trial by Veronesi- were the pioneering trials in establishing SLNB (6,7). These trials
randomized patients of T1/2 N 0 breast cancer to SNB followed by axillary clearance versus SNB alone. In both
these trials, the rate of identification of the sentinel node was around 95-97 % with a false positive rate of around
5-8%. The axillary recurrence rates, disease free survival and overall survival with SNB were equivalent to
standard axillary clearance with much lower morbidity in terms of lower rates of lymphedema, shoulder pain and
shoulder dysfunction. These trials thus established the safety and efficacy of SNB as an alternative to standard
axillary clearance for early N0 breast cancer with a better morbidity profile.
Subsequently the ACOSOG Z- 0011 and the IBCSG 23-01 trials evaluated the necessity of completion
axillary clearance in clinically N0 cases who have a positive node on SNB (8,9). These trials demonstrated
that patients with upto 3 nodes positive on SNB have no benefit from further axillary clearance. Thus such
patients can be safely treated with tumor removal and SNB alone and no further axillary surgery.
Current guidelines for SNB in breast cancer-
Indicated for
T1/2, clinically N 0 breast cancer cases. (Clinically N 0 means a negative axillary examination
clinically and on USG for obese patients in whom axillary evaluation by palpation is difficult )
Patients with DCIS who are undergoing mastectomy (up to 10 % incidence of nodal
involvement is reported in such cases)
Combination of both blue dye and radioisotope is recommended. Site of dye injection-
intradermally over the lump or subareolar.
Contraindicated in pregnancy because of teratogenic effect of isosulfan blue and the radioisotope
Management after sentinel lymph node biopsy — Based upon pathologic results obtained by
SLNB, no further axillary treatment for patients who meet all of the following criteria ("Z-0011-
eligible" criteria) ●Clinically negative nodes based on an adequate clinical node evaluation,
including imaging when necessary, such as in obese patients.
●A T1 or T2 (≤5 cm) primary breast cancer
●Fewer than three metastatic sentinel lymph nodes on SLNB.
●Patients undergoing breast conserving surgery followed by whole-breast
irradiation. A completion ALND is required for patients who have:
●Three or more metastatic sentinel lymph nodes on SLNB.
●One or two metastatic sentinel lymph nodes on SLNB but who do not desire whole-breast irradiation.

SNB FOR MALIGNANT MELANOMA

SNB is recommended for patients with intermediate-thickness melanomas (Breslow thickness, 1-4
mm) of any anatomic site. Use of SLN biopsy in this population provides accurate staging (10).
Although there are few studies focusing on patients with thick melanomas (T4; Breslow thickness, >4 mm),
SLN biopsy may be recommended for staging purposes and to facilitate regional disease control.
There is insufficient evidence to support routine SLN biopsy for patients with thin melanomas (T1;
Breslow thickness, <1 mm), although it may be considered in selected patients with high-risk features
when staging benefits outweigh risks of the procedure.
Completion lymph node dissection (CLND) is at present recommended for all patients with a positive
SNB biopsy and achieves good regional disease control.
Whether Completion lymph node dissection after a positive SNB biopsy improves survival is the
subject of the ongoing Multicenter Selective Lymphadenectomy Trial II.
SNB FOR OTHER MALIGNANCIES
SNB is being currently considered experimental for use in head and neck cancers, colorectal,
oesophageal and gastric cancers.

24
REFERENCES
D’Cruz AK, Vaish R, Kapre N, Dandekar M, Gupta S, Hawaldar R, et al. Elective versus therapeutic neck dissection in
node-negative oral cancer. N Engl J Med. 2015;373:521–9.
Horenblas S, van Tinteren H, Delemarre JF, Moonen LM, Lustig V, Kröger R. Squamous cell carcinoma of the penis:
Accuracy of tumor, nodes and metastasis classification system, and role of lymphangiography, computerized
tomography scan and fine needle aspiration cytology. J Urol.1991;146:1279–83.
Morton DL, Thompson JF, Essner R, et al. Validation of the accuracy of intraoperative lymphatic mapping and
sentinel lymphadenectomy for early-stage melanoma: a multicenter trial. Multicenter Selective Lymphadenectomy
Trial Group. Ann Surg.1999;230:453–65.
Giuliano AE, Jones RC, Brennan M, Statman R. Sentinel lymphadenectomy in breast cancer. J Clin Oncol.
1997;15:2345– 2350.
Krag DN, Weaver DL, Alex JC, Fairbank JT. Surgical resection and radiolocalization of the sentinel lymph node in
breast cancer using a gamma probe. Surg Oncol. 1993;2:335–339. discussion 340.
Krag, D.N., Julian, T.B., Harlow, S.P. et al. NSABP-32: Phase III, randomized trial comparing axillary resection with
sentinal lymph node dissection: a description of the trial. Annals of Surgical Oncology (2004) 11(Suppl 3): 208S.
Veronesi U, Paganelli G, Viale G, et al. A randomized comparison of sentinel-node biopsy with routine axillary
dissection in breast cancer. N Engl J Med. 2003;349(6):546:53.
Giuliano AE, McCall L, Beitsch P, et al. Locoregional recurrence after sentinel lymph node dissection with or
without axillary dissection in patients with sentinel lymph node metastases: the American College of Surgeons
Oncology Group Z0011 randomized trial. Ann Surg 2010;252:426-32; discussion 432-3
Galimberti, V, Cole, BF, Zurrida, S et al. Axillary dissection versus no axillary dissection in patients with sentinel-
node micrometastases (IBCSG 23-01): a phase 3 randomised controlled trial. Lancet Oncol. 2013; 14: 297–305.
National Comprehensive Cancer Network. Melanoma: Clinical Practice Guidelines in Oncology. version 2. 2017.
National Comprehensive Cancer Network.

Modified Radical Mastectomy

-Dr. Rajdeep Singh, Dr. Nikhil Talwar

INTRODUCTION
Over the years, there have been two major approaches to the management of breast cancer. William Halsted
(1894) believed that cancer, especially breast cancer, starts as a local disease and then spreads out via local
extension and lymphatic spread. Based on this theory, he advocated more and more radical procedures. In
those days, before modern chemotherapy and advanced anaesthesia were available, his results were
remarkable and deserve respect. Bernard Fisher in 1950-85 propounded that breast cancer is a systemic
disease from the beginning itself, and thus surgery has little role. He incidentally was involved in
conducting the first randomized trial on the subject. The Halstedian approach was favoured by surgeons,
who resisted Fisher’s chemotherapy-based theory for many years.
As with any two extreme approaches, the truth lies somewhere in the middle. Hellman in 1993
stressed that belief in one or the other is nothing but dogma, which needs to be changed. The Hellman
hypothesis describes breast cancer as a spectrum of disease, ranging from local disease (managed
surgically) to one which metastasizes early.

The original radical operation of Halstead radical mastectomy1 consisted of en bloc removal of the
breast, the overlying skin, both the pectoralis major and minor muscles, in continuity with the regional
lymph nodes along the axillary vein to the costoclavicular ligament (level I, II, and III nodes). The long
thoracic nerve and the thoracodorsal neurovascular bundle with the axillary contents were routinely
resected. This procedure often required a skin graft to close the large skin defect created.
Extended radical mastectomy was a logical extension to a Halsted radical mastectomy, which
achieved more radical lymphatic clearance by excision of the internal thoracic and supraclavicular
nodes. An even more radical mastectomy was the “super-radical” mastectomy that included four
parts: Breast and axillary contents, Internal mammary artery and vein with internal mammary lymph
node chain, upper mediastinal nodes and low supraclavicular nodes.

Modified Radical Mastectomy

Currently, there is practically no role of radical mastectomy. The maximum surgical intervention is in the form of a
Modified radical mastectomy. Unfortunately, the modification is not standardized. In 1948, Patey and Dyson of the
Middlesex Hospital, London, advocated a modified radical mastectomy (MRM) for the management of advanced
operable breast cancer. They preserved the pectoralis major muscle and the lateral pectoral nerve and sacrificed
the pectoralis minor muscle and medial pectoral nerve to allow clearance of axillary lymph node levels I to III.
Scanlon modified the Patey procedure by dividing but not removing the pectoralis minor muscle, allowing removal
of level III nodes and preservation of the lateral pectoral nerves to the Pec major muscle.
The procedure described by Auschincloss (and Madden) differs from the Patey procedure by not removing
or dividing the pectoralis minor muscle. This modification limits the complete removal of high axillary nodes
but is justified by Auchincloss, who calculated that only 2% of patients will potentially benefit by removal of
the highest level nodes. The Auchincloss mastectomy is the most popular form of MRM in the present era.
25
Since the technique of MRM is not self evident, many centres now use the term “Total mastectomy
with axillary clearance” , which means the same thing.

Technique
A modified radical mastectomy removes all breast tissue, the nipple-areola complex, necessary
overlying skin, and the level I and II axillary lymph nodes.

After the induction of general anesthesia, the patient is positioned supine with the arm abducted to 90
degrees on an armboard. Some surgeons prefer placing a small sandbag below the shoulder to elevate the
axilla. The arm is not secured to the armboard for the MRM so that it may be brought into the operative field
during surgery. The chest, axilla, and entire arm are prepared and draped in sterile fashion. The prepared
area should extend sufficiently beyond the breast so that landmarks can be easily identified: across the
midline, to the costal margin, the base of the neck, and laterally to the operating room table, including
around the shoulder. The forearm and hand are draped in a towel secured with a bandage.

Incisions
The standard incision for a mastectomy is an elliptical skin incision including both the nipple-areola
complex and the previous biopsy incision (if any). The ellipse may be oriented either transversely or
obliquely. The choice of incision must be based on the size of the breast, body habitus of the patient, and
size and location of the tumor (or biopsy cavity). Care should be taken to make the ellipse wide enough that
redundant skin is avoided, including dog-ears, but not so wide that the closure is excessively tight.
Extension in to the axilla should be avoided; a complete axillary dissection can be performed through the
standard incisions. Undue tension may lead to vascular compromise of the flaps.
There are several options for how this ellipse is oriented. The classic Stewart incision results in a
transverse scar (Fig. 5). It should begin at the lateral margin of the sternum and end at the anterior
margin of the latissimusdorsi. The Stewart incision may be modified to lie obliquely, so the final
incision extends superiorly at the lateral margin.

Fig. 1:The classic Stewart elliptical skin incision for central and Fig. 2: The modified Stewart oblique elliptical skin incision for inner

The other popular incision is the Orr oblique incision. As opposed to the modified Stewart incision, which extends
slightly superiorly in the lateral margin, the Orr incision is an oblique incision (Fig. 3,4). This approach is ideal for
upper, outer quadrant incisions but, as with the Stewart incision, can be used for most tumors. The elliptical
incision of the breast skin incorporates the nipple-areola complex and skin overlying the breast cancer en bloc
with skin margins that lie 1 to 2 cm from the cephalad and caudad extents of the cancer.

Raising of skin flaps

Skin flaps are developed using cautery or scalpel and extend to the boundaries of dissection for the
modified radical mastectomy, which are: (a) the anterior margin of the latissimus dorsi muscle
laterally, (b) the lateral border of the sternum medially, (c) the subclavius muscle superiorly, and (d)
the superior extent of rectus sheath inferiorly.

The skin incision is then made with a scalpel, dividing the skin and superficial fascia just until the
breast tissue is evident. Several superficial veins need to be cauterized. Once the skin incision is
completed, the superior flap is raised. The skin edges are elevated at a right angle to the chest wall to
adequately expose the superficial fascia. The appropriate dissection plane for skin flap elevation is
deep to the subcutaneous vasculature and superficial to the vessels of the breast parenchyma.

26
The surgeon elevates the skin flap with consistent thickness to avoid creation of devascularized
subcutaneous tissues. If cautery is used, it should not be maintained in one position for too long a
period of time to avoid thermal injury to the flap.

Fig3:The classic Orr oblique elliptical skin incision Fig. 4:Variation of the Orr oblique elliptical incision for lower inner
quadrant and lower midline (6 o'clock) breast cancers.

Elevation of the breast parenchyma

Once the skin flaps are developed, the breast parenchyma and pectoralis major fascia are elevated from the
underlying pectoralis major muscle in a plane parallel with the muscle bundles as they course from their
medial origin (ribs 2 to 6) to their lateral insertion on the humerus. Perforating vessels from the lateral
thoracic or anterior intercostal arteries, which are end arteries that supply the pectoralis major and minor
muscles and breast parenchyma, are regularly encountered and cauterized. Elevation of the breast
parenchyma and pectoralis major fascia is continued laterally until the lateral edge of the pectoralis major
muscle and the underlying pectoralis minor muscle are exposed. The laterally placed neurovascular bundle
in which the medial pectoral nerve innervates the pectoralis major and minor muscles is preserved to
prevent atrophy of the lateral head of the pectoralis major, a significant cosmetic and functional defect.

Axillary Dissection
As the breast is removed from the lateral border of the pectoralis major muscle, the space between the
pectoralis major and minor muscle can be developed so that palpation of the interpectoral (Rotter’s) nodes
can be undertaken. Some surgeons only remove this tissue when palpable nodes are detected; other
surgeons routinely include the fibroareolar tissue in the interpectoral space, which can be swept laterally
and included with the specimen. However, excessive dissection in this area can lead to injury of the lateral
pectoral nerve and is unlikely to be of added benefit if grossly involved nodes are not present. The investing
fascia of the axillary space is sharply divided, the pectoralis minor muscle is defined, and lymph nodes,
which may lie between the pectoralis muscles (Rotter nodes), are cleared. As the axillary lymph node
dissection proceeds, the loose areolar tissue of the lateral axillary space is elevated with identification of
the lateral extent of the axillary vein in its course anterior and caudad to the brachial plexus and axillary
artery (the axillary contents can also be removed in a medial to lateral direction). The investing layer of the
axillary vein is dissected sharply, with dissection allowing complete visualization of the anterior and ventral
surfaces of the vein. Ligation and division of intervening venous tributaries is performed. Dissection
continues medially on the anteroventral surface of the axillary vein, and the loose areolar tissue at the
juncture of the axillary vein with the anterior margin of the latissimusdorsi muscle is swept inferomedially to
include the lateral group of axillary lymph nodes (level I).

The intercostobrachial nerves are visualized, and course through the level II axillary lymph nodes that lie below
the axillary vein. Generally, no attempt is made to preserve the branches of the intercostobrachial nerve. The
thoracodorsal artery and vein are preserved- they are located deep in the axillary space and are invested with
loose areolar tissue and the axillary lymph nodes of the lateral and subscapular groups. The thoracodorsal nerve
originates from the posterior cord medial to the thoracodorsal artery and vein and is visualized and protected
along its variable inferolateral course en route to its innervation of the latissimus dorsi muscle. The lateral axillary
lymph node group is retracted inferomedially and anterior to the thoracodorsal neurovascular bundle and
dissected en bloc with the subscapular group of axillary lymph nodes (level I), which are medially located between
the thoracodorsal nerve and the lateral chest wall. Dissection of the posterior contents of the axillary space
exposes the posterior boundary of the axilla, allowing visualization of the heads of the teres major muscle laterally
and the subscapularis muscle medially.

27
 Fig. 5: Initiation of the modified radical mastectomy. Fig. 6: Elevation of the breast and pectoralis major fascia
Development of skin flaps. off of the underlying muscle. Dissection should proceed
superior to inferior and medial to lateral.
Dissection then proceeds medially with extirpation of the central axillary lymph node groups (level II).
A level III dissection is generally considered unnecessary (unless there is grossly apparent disease
present in the axillary apex) because skip metastases to level III only occur in 2% to 3% of cases and
due to increased incidence of lymphedema. The surgeon continues the dissection en bloc to avoid
separation of nodal groups and disruption of lymphatic vessels in the axilla.

Fig. 7:Exposure of the pectoralis minor muscle and incision of the investing fascia of the axilla.

With medial dissection, the surgeon encounters the chest wall deep in the medial axillary space and is able
to identify and preserve the long thoracic nerve (of Bell), which is constant in its location, anterior to the
subscapularis muscle, and is closely applied to the investing fascial compartment of the chest wall. The
long thoracic nerve is dissected along its course to where it innervates the serratus anterior muscle.
Damage to the nerve causes permanent disability with a winged scapula deformity. When level III
lymphadenopathy is present, a Patey modification of the modified radical mastectomy may be
employed. As dissection proceeds medially along the lateral margin of the pectoralis major muscle,
abduction of the shoulder and extension of the arm along with finger dissection at the lateral margin
of the pectoralis major muscle allows visualization of the insertion of the pectoralis minor muscle on
the coracoid process of the scapula.

Closure
Once the axillary lymph node dissection is complete, the surgical bed is irrigated with normal saline to
evacuate residual tissue, blood clots, and serum. Bleeding points are identified and cauterized or ligated.
Just prior to closure, two closed-suction drains are typically placed through two different stab incisions
inferiorly. The laterally placed drain is positioned in the axillary space approximately 2 cm inferior to the
axillary vein on the ventral surface of the latissimus dorsi muscle to provide drainage of the axilla. The
medially placed drain is positioned under the skin flaps. Both drains are secured to the skin with a 2-0 silk
suture and are connected to the suction reservoir. The wound is closed with 3-0 or with 4-0 nylon suture.
28
 Fig. 8: The completed axillary lymph node dissection. In this illustration, the pectoralis minor muscle has been resected (Patey modification).The

medial and lateral pectoral nerves, the thoracodorsal neurovascular bundle, and the long thoracic nerve are preserved.

Postoperative Care
Wound dressings are removed after 2-5 days. The drainage catheters remain in place until drainage
becomes serous or serosanguineous in character and decreases to less than 30 mL per 24 hours for a
48-hour period. Generally, the catheters are removed between postoperative days 5 and 7, but, when
necessary for continued high-volume drainage, can remain until postoperative day 10. Range-of-
motion shoulder exercises begin 24 hours after surgery.
Complications
Wound complications occur in up to 30% of cases. These include flap necrosis, infections, seromas,
and hematomas. Flap necrosis and epidermolysis occurs in 18-30% of all mastectomies. Brachial
plexopathy may occur related to a stretch injury of a malpositioned patient.
Major Complications of Axillary Lymph Node Dissection
Seroma, Infection, Paresthesia, Chronic pain, Shoulder immobility, Axillary vein thrombosis,
Thoracodorsal nerve injury, Long thoracic nerve injury (winged scapula), Brachial plexopathy, Arm
lymphedema, Breast lymphedema.

Anatomic Complications of the Modified Radical Mastectomy

Vascular Injury
The first and second perforating vessels are too large for cautery. They are ligated.
The axillary vein, if torn, is repaired. Ligation may cause chronic edema.
Nerve Injury
Intercostobrachial nerve When cut circumscribed numbness of the medial aspect of
the ipsilateral upper arm results.
Long thoracic nerve If cut, a winged scapuladeformity results
Medial and lateral thoracic nerves If cut, the pectoralis muscles atrophy.
Thoracodorsal nerve If cut, internal rotation and abduction of the shoulder are
weakened.

Lymphedema
The most significant complication of an ALND is lymphedema of the upper extremity. Approximately
10% to 30% of patients who have an ALND will experience lymphedema. Risk factors for lymphedema
among patients undergoing axillary surgery
Extent of surgery:increased risk after level I,II,III dissection compared to level I,II
dissection Radiation
Infection
Regional recurrence
Inflammatory diseases (rheumatoid
arthritis, chronic dermatitis)
Venous obstruction
Obesity
Air travel
29
References
Halstead WS. The results of operations for the cure of cancer of the breast performed at the John Hopkins Ho spital from
June 1889 to January 1894. Ann Surg 1894; 20: 497–555.
Haagenson CD. The history of surgical treatment of breast carcinoma from 1863 to 1921. In: Diseases of the breast, 3rd ed. W.B.
Saunders, Philadelphia 1986: 864-871
Dixon JM, Soon PSH. Breast-Conserving Surgery. In: Fischer, Josef E (eds): Mastery of Surgery. 5th ed. Lippincott Williams & Wilkins;
2007:502-517.
Fisher B, Anderson S, Bryant J, et al. Twe nty-year follow-up of a randomized trial comparing total mastecctomy,
lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med 2002;347:1233.
Burstein HJ, Harris JR, Morrow M. Cancer of the Breast- Malignant Tumors of the Breast. In: DeVita VT, Lawrence TS, Rosenberg SA
(eds.) Devita, Hellman & Rosenberg's Canc er: Principles & Practice of Oncology. 8th ed. Lippincott Williams & Wilkins;
2008:1606-1654.
Sabel MS. Locoregional therapy of breast ca ncer: Maximizing control, minimizing morbidity. ExpRev Anticancer Ther
2006;6(9):1281– 1299.
Souba WW, Bland KI: Indications and tec hniques for biopsy. In Bland KI, Copeland EM III (eds) The Breast: Comprehensive
Management of Benign Malignant Diseases. Philadelphia: WB Saunders, 1998: 802-809
Allweis TM, Badriyyah M, Bar Ad V, et al. Current controversies in sentinel lymph node biopsy for breast canceer. Breast 2003;12:163.
Bland KI, Beenken SW. Modified Radical M astectomy with Immediate or Delayed Breast Reconstruction. In: Fischer, Josef E
(eds): Mastery of Surgery. 5th ed. Lippincott Williams & Wilkins; 2007:530-544.
Tuttle TM, HabermanEB, Grund EH et al. Inc reasing use of contralateral prophylactic mastectomy for breast cancer patients:
a trend toward more aggressive surgical treatment. J Clin Oncol 2007;25(33):5203–309.

Axillary Dissection
-Dr. Anurag Mishra
Introduction
The axilla is a quadrangular space that lies between the following:
The lower border of the axillary vein
superiorly The chest wall medially
The axillary skin laterally
Pectoralis major and minor anteriorly
Latissimus dorsi, teres major, and subscapularis posteriorly
It lodges fat, vessels to upper limb, ner ves (long thoracic nerve, thoracodorsal nerve, medial pectoral nerve)
and lymph node draining ipsilateral upp er limb and skin and subcutaneous tissue of anterio r abdominal wall
of ipsilateral side cranial to umbilicus. Alth ough the nodes are in a continuum, the clearance can be
anatomically divided into three levels based on the rel ationship of the tissue to the pectoralis minor muscl e.

30
Axillary dissection is a surgical procedure that incises the axilla to identify, examine, or remove lymph
nodes from axilla. Typically level I (lateral to Pectoralis minor muscle) and level II (deep to pectoralis
minor muscle) nodes are removed. Axillary dissection has been the standard technique used in the
staging and treatment of the axilla in breast cancer.
Staging of the axilla is an important step in the treatment of breast carcinoma. Axillary lymph node
status is a significant prognostic pathologic variable in patients with operable primary breast cancer,
and it remains the most powerful predictor of recurrence and survival.
Axillary dissection was first advocated as part of the treatment of invasive breast cancer in the 18th
century by Lorenz Heister, a German surgeon. In modern practice, the role and benefits of axillary
dissection have been influenced by the National Surgical Adjuvant Breast Project (NSABP)-B-04 trials,
which concluded that axillary dissection has no effect on survival. However, other studies provided
substantial evidence that axillary dissection provides excellent local control of disease in the axilla,
with a local recurrence rate of 2% or less, which may lead to improved overall survival.
Indications
Axillary dissection is indicated in
Patients with proven axillary disease
Positive sentinel node biopsy.
Since sentinel Lymph-node biopsy (SLNB) was introduced, axillary dissection is not required for all
cases of malignancy (eg Breast), as the status of the axilla in N0 cases can be established without
morbidity of complete axillary dissection. SLNB thus saves 60% cases from overtreatment. For Node
positive cases axillary dissection is therapeutic and is indicated
Recently there may be a gradual shift away from carrying out an axillary clearance in patients with positive
sentinel nodes. A recent trial (AMAROS), found no significant difference in disease-free or overall survival
when it compared the use of axillary radiotherapy as against surgical axillary clearance in patients who had
a positive sentinel node. But the incidence of lymphedema was significantly less in the radiation group.
Axillary dissection is advocated for all patients who complete neoadjuvant treatment to down-stage the breast
tumor, except when sentinel node biopsy is negative and undertaken prior to the neoadjuvant treatment.

Contraindications
None

Procedure Planning
FNAC is required in suspicious nodes. Most patients with palpable axillary nodes, if proceeding to
surgery, generally do not require cytological/histological confirmation of nodal involvement.
The patient can be taught a full range of shoulder exercises preoperatively. The range of
shoulder movement should be assessed preoperatively.Postoperatively, the same exercises
are encouraged to ensure full mobility.
Patients are generally advised to avoid any heavy lifting with the arm on the side of the cancer,
which will potentially reduce risk of lymphoedema and also avoid any unnecessary trauma,
including iatrogenic intervention on that arm to reduce risk of infection.
Well Informed consent to be obtained and side to be operated is marked on night before surgery.

Anesthesia
General Anaesthesia is preferred.

Positioning
Confirm and mark the correct surgical site preoperatively.
Patients are positioned lying supine, with the arm abducted and placed on an arm board at 90
degrees to the chest wall.
If required, shave/ clip the hairs from surgical site. Prepare and drape the surgical site in
standard surgical way. The arm can be draped separately in a sleeve to facilitate complete arm
movement for the axillary dissection.
The head end is raised to 30 degrees.
The shoulder can be flexed to facilitate dissection of axillary level III nodes.

Technique
Incision: Axillary dissection can be carried out through the incision for a mastectomy. Patients
having lumpectomy usually require a separate incision in the axilla. Often, the preference is for
a skin crease incision just below the axillary hairline extending from the posterior edge of the
pectoral fold to the posterior axillary line. (Fig 1 and 5)
Flaps are raised off the skin and subcutaneous tissue. (Fig 6)
Dissection is carried past the edge of pectoralis major muscle. Retraction of the pectoralis
major medially exposes the pectoralis minor and the clavipectoral fascia. The lateral pectoral
nerve bundle is identified and preserved. (Fig 7)
31
 Incision into the clavipectoral fascia allows entry into the axillary fat and the conta ined nodes.
These are removed en bloc through the surgery. (Fig 8)
Dissection is carried superiorly along the edge of the pectoralis minor to reach the inferior edge
of the axillary vein. Once the axillary vein is identified, this is followed medially to reac h the
axillary apex, where the axillary vein crosses the lateral border of the first rib. (Fig 9-10)
The axillary contents are then s eparated from the lateral thoracic wall, which is the medial
boundary of the axilla. This exposes the lon g thoracic nerve, which supplies the serratus anterior
muscle (injury to which would lead to winging of the scapula). During this dissection, branches of
the intercostobrachial nerve will be identified as they cross the axilla after emerging from the
intercostal spaces. The larger trunks should be preserved if possible. (Fig 12)
Ligation and division of the s maller tributaries of the axillary vein as they ent er the axilla allows
visualization and identification o f the subscapular vessels and thoracodorsal nervee as they
reach the subscapular and latissimus dorsi muscles posteriorly. (Fig 11)
The axillary fat and nodal tissue between the long thoracic nerve and the subscapu lar vascular
bundle is carefully dissected. Often, this is performed en bloc with the specimen, although it
sometimes can occur separately if there is exten sive nodal involvement.
The dissection then proceeds towards the apex to include the nodes medial to the pectoralis
minor (Berg level III). This is facilitated by flexion of the free draped arm at the shoulder.
The axillary fat and nodes are fi nally separated from the axillary tail of the breast to allow the
specimen to be excised.
Careful pathological examination for an axillary dissection will often reveal in excess of 20 lymph
nodes. The wound is closed in layers ov er a suction drain.

Complications
Pain: Axillary dissection is not very painful. The patient may feel slight discomfort a nd soreness
at the wound site, which is easily mana ged by taking mild analgesics.
Wound infection: A slight risk of wound infection exists after breast surgery, which may result in
wound breakdown.
Hematoma: Rarely hematoma might develops which generally happens within 24 hours after the
operation.
Bruising: Patients may notice sw elling of the wound site and bruising over the breast or axilla.
Seroma: The observed rates of seroma after axillary surgery range from 2.5-51%. It may
necessitate needle drainage on one or multi ple occasions.
Shoulder stiffness: It is a temporary and self-limited side effect. Physiotherapy can be beneficial.
Lymphedema of the arm and breast: It constitutes significant long-term sequelae to axillary
dissection. This is minimized by limiting the dissection superior to the axillary vein.
A numb patch on lateral wall of axilla on the upper arm may be caused by division of
intercostobrachial nerve

32
 BREAST RECONSTRUCTION
-Dr. Raghav Mantri

Breast is a symbol of feminity and the loss of breast has profound physical and psychological consequences.
Mastectomy is a mutilating surgery which causes the loss of self esteem in the patient. Although breast
conservation surgery is an excellent choice for many women with cancer, a large number of these women are not
happy with their final outcome. Also mastectomy is still an integral part of treatment algorithm with the advent of
genetic testing for mutations in BRCA genes, prophylactic mastectomies are gaining acceptance.
Breast reconstruction is an excellent procedure to solve many of the problems associated with mastectomy.
A woman with successful breast reconstruction can return to an active and productive life as most of them
are in the prime of their life. The goal of breast reconstruction is to return the patient to a state that
approximates the normal as closely as possible. The reconstructed breast should be shaped naturally, is
soft, moves like real breast and in short looks and feels like a normal breast.
Breast reconstruction can be done immediately after mastectomy in the same sitting on it can be
delayed as a second stage surgery after completing radiotherapy. (All the patients of breast cancer
should be given a choice of breast reconstruction during initial discussion with oncosurgeon and
should be referred to a plastic surgeon). The mastectomy defect can be devastating both physically &
psychologically. Numerous studies have documented the significant improvement in self confidence
and mental health following breast reconstruction. It has also been proven in many studies that breast
reconstruction doesn’t delay the diagnosis of cancer recurrence.
Delayed breast reconstruction is usually reserved for patients who will require post mastectomy radiotherapy
although this remains controversial. Procedures for reconstruction include alloplastic techniques such as tissue
expander/implant or autologous techniques with numerous tissue flaps on a combination of both. No one
procedure is fit for all patients. The choice of a particular procedure in a patient depends on various factors like
the stage of disease, the need for radiation after surgery, the size of contralateral breast, the age of patient,
obesity, history of smoking, surgeon’s experience and last but not the least, the patient’s choice.

Alloplastic reconstruction with implant offers the reformation of a breast mound through a less
invasive procedure and offers good cosmetic results. It is particularly beneficial in bilateral
reconstruction, where obtaining symmetry is easier. But this procedure is not feasible in many
patients due to lack of adequate skin envelope for tension free coverage. Also muscle coverage of
implant is partial which is not ideal. A combined approach with latissimus dorsi myocutaneous flap for
coverage and implant for volume is an excellent choice for most patients. Latissimus dorsi is a flat
large muscle on the back. It has a very robust blood supply from the thoracodorsal vessels.
The lower abdomen is a very good donor site for breast reconstruction. There are a number of advantages to
using donor tissue for the abdomen. First, because of a characteristic infraumblical fat deposit in females, the
transverse rectus abdominis myocutaneous (TRAM) flap almost always provides enough soft-tissue bulk for
reconstruction of the breast mound. Second, in patient without complications, the vascular supply is reliable.
Finally, the resultant scar and abdominal contour are similar to those following an abdominoplasty.
The blood supply of the pedicled TRAM flap is derived from the superior epigastic artery by means of a series of
choke vessels with the rectus abdominis muscle. After harvest of the flap, a subcutaneous tunnel from the
abdominal donor site to the mastectomy defect is created to accommodate the flap. Either the ipsilateral,
contralateral, or bilateral rectus muscles may be used. In patients with risk factors such as obesity, smoking and
prior irradiation, a “delay procedure” may be performed at least 2 weeks before the pedicle procedure.

The free TRAM flap is based on the more dominant inferior epigastric vascular pedicle, permitting transfer of large
volumes of tissue with minimal risk of fat necrosis. As opposed to Hartrampf’s description of zones of perfusion in
a pedicled TRAM flap, the best perfused areas of a free TRAM flap lie within the hemi abdomen that is ipsilateral to
the pedicle. Because of the robust blood supply to a free TRAM flap, the procedure can be used with greater
degree of safety in patients with risk factors such as tobacco use, diabetes, and obesity. Micro vascular
anastomoses are generally performed to the thoracodorsal or internal mammary vessels. In setting of the free
tissue transfer is facilitated because the flap is not tethered by a pedicle. In addition, the potential upper
abdominal contour deformity arising from the bulk of the transposed pedicled flap is eliminated.
The muscle-sparing TRAM flap, which is limited to the portion of muscle and anterior rectus sheath
that encompassed the lateral and medial rows of perforating vessels, is a modification of the TRAM
flap that theoretically minimizes violation of the abdominal wall and the risk of donor-site morbidity. A
more comprehensive understanding of the evolution of the muscle –sparing TRAM flap of the deep
inferior epigastic perforator (DIEP) flap is reflected in the classification system described by
Nahabedian et al. The muscle-sparing TRAM flap can be performed as a pedicled flap, although it is
more commonly used as a free tissue transfer.

33
Classification of Muscle-Sparing Free TRAM flaps
Muscle- Sparing Technique Definition (Rectus Abdominis)

MS 0 Full width, partial length harvested

MS 1 Preservation of lateral segment
MS 2 Preservation of medial and lateral segments
MS 3 (DIEP) Preservation of entire muscle

The DIEP Flap is a refinement of the conventional muscle-sparing free TRAM flap .Transmuscular
perforators originating from the deep inferior epigastric artery perfuses the overlying skin and
subcutaneous tissue. When a perforating vessel is found, it is dissected away from the surrounding
muscle and traced to its origin from the vascular pedicle. Because no muscle is harvested, donor-site
morbidity is minimized. Harvesting of the DIEP flap can be a tedious dissection. Moreover, flap
vascularity may be less than that of the perforating vessels in some patients. Higher risk of venous
insufficiency, partial flap loss, and fat necrosis compared with free TRAM flaps has been reported.
Unlike the free TRAM and DIEP flaps that are based on perforating vessels, the superficial inferior
epigastric artery (SIEA) flap is a direct axial adipo-cutaneous flap. The SIEA arises from the common
femoral artery and supplies the ipsilateral lower abdominal skin and fat; the flap can be elevated from
the anterior recuts sheath without excision or incision of the rectus abdominis muscles, theoretically
eliminating potential abdominal will morbidity. However, because the superficial epigastic vessels are
inadequate in up to 70 percent of patients, SIEA flap use is limited.

Non-abdomen-Based Reconstruction
A patient desiring a TRAM or related flap must have adequate tissues in the lower abdomen to be considered a
candidate. In addition, a patient’s lifestyle must allow for the potential diminution of truncal strength. Inadequate
abdominal fat in a patient with a slender body habitus with or without a high-risk abdominal scar is one of the
primary reasons for using an alternate flap. Although the soft tissue of the gluteal region provides ample volume
for creating a breast mound, the gluteal perforator flap is still considered by most to be second-line choice for
autogenous breast reconstruction. This is because surgical dissection can be complex, intraoperative
repositioning of the patient necessitates increased operative time, and failure rates are higher. Compared with the
superior gluteal flap, the scar from the inferior gluteal arterial perforator flap can be concealed in the inferior
gluteal crease, and its vascular pedicle is relatively longer. However, a disadvantage of the inferior gluteal arterial
perforator donor site is the potential for sciatic nerve irritation.
The transverse upper gracilis flap uses a transverse skin island that overlies the gracilis muscle and is
transferred on the medial circumflex femoral artery. Complications include widened scars, lowerlimb
lymphedema, and higher rates of secondary surgery needed to augment its volume. We consider transverse
upper gracilis a second-line choice and reserve it exclusively for immediate reconstruction of small breasts.

Complications
Implant Reconstruction
Early complications associated with tissue expander/implant reconstruction include infection, hematoma,
seroma and mastectomy skin flap necrosis. Infection, malposition, deflation, and exposure of the device
secondary to skin flap necrosis are among the conditions that may necessitate tissue expander or implant
removal. Although acute extrusion and implant loss are rare, late reoperation rates are reported as high as
30 percent. However reported reoperation rates are difficult to compare as different definitions and follow-
up times are used in different studies. Capsular contractures implant dislocation, visible wrinkling, and
deflation are among the late complications that may require surgical intervention. In addition to structural
complications, a possible link between T-cell anaplastic large-cell lymphoma of the breast and implants is
under investigation. Anaplastic large-cell lymphoma is rare, representing 0.9percent of all cases of non-
Hodgkin’s lymphoma diagnosed in the United State in 2010.

Autogenous Reconstruction
Acute complications associated with autogenous tissue include wound-related and ischemic complications
at the donor and /or recipient site: infection, seroma, hematoma, delayed healing, wound dehiscence, and
fat and skin flap necrosis. The incidence of fat necrosis and partial flap loss approaches 5 percent in most
free TRAM flaps compared with 15 to 20 percent in pedicled TRAM flaps. The rate of total flap loss is 1 to 2
percent in most pedicled and free TRAM flap series. Smoking, chest wall irradiation, significant abdominal
scarring, and obesity are associated with increased complication rates. Long-term complications of
autogenous reconstruction are related primarily to donor-site morbidity. Data accumulated over the past
decade show that muscle and fascial-sparing techniques (e.g. DIEP flaps) results in measurably better
postoperative truncal strength. Postoperative abdominal hernia or, more commonly, abdominal wall laxity
remains a persistent issue for some patients choosing TRAM flap reconstruction. Interestingly, muscle-
sparing technique does not appear to decrease the risk of abdominal bulging or hernia formation.

34
Nipple –Areola Complex Reconstruction
After recreation of the breast mound with either form of reconstruction, many women opt to have the nipple-
areola complex recreated as a final step in restoring body image. Techniques are broad and include grafting
skin, buccal mucosa, labia minora or m ajora, thigh, buttocks, groin, upper eyelids, or earlobes. Although the
technique varies, the principle remain the same: to provide color, texture, size, and projectio n that are all in
line with the patient’s aesthetic wishes. Many of the earlier methods suffered from loss of projection over time
and difficulty with color matching and stability. The most common method used today consists of local skin
flap rearrangement to create texture and pro ection followed by tattooing for color. Nipple-areola formed more
than 3 to 4 months after mound reconstruction. This allows for complete healing of the flap and ensures stable
mound symmetry which is an important prerequisite before recreating a nipple-areola complex. Immediate
nipple-areola complex recreation at the time of flap surgery has been reported but by far is less commmon.
Breast reconstruction is becoming increasingly popular and important to many women following
treatment for breast cancer. There are many options available to plastic surgeon, but ultimately which
technique is used should be based on surgeon familiarity, hospital resources and the patient’s wishes.
All ca n be offered with a high degree of patient satisfaction and a low rate of complications.

TONGUE CANCER
-D r. Nitin Leekha

Cancer of the oral cavity is the most c mmon cause of cancer in Indian males. Oral canccer ranks in the top
three of all cancers in India, which acco unts for over thirty per cent of all cancers reported in the country and
oral cancer control is quickly becoming a global health priority.Oral cancer is of signifficant public health
importance to India. Firstly, it is diagnosed at later stages which result in low treatm ent outcomes and
considerable costs to the patients whom typically cannot afford this type of treatment. Secoondly, rural areas
in middle- and low-income countries also have inadequate access to trained providers and limited health
services. As a result, delay has also been largely associated with advanced stages of oral cancer.
Age standardized incidence rate in Indi a is 7.5 per 100,000 population while in western Eu urope and USA
it is 4.6 and 3.8 per 100,000 population respectively 4. A recent national representative survey o f cancer
mortality in India demonstrated oral cavity cancer as the leading cause of mortality in men which was
responsible for cancer-related deaths in 22.9% cases.
Tongue forms the most common sub-site for oral cavity cancer in western world. While ging ivo-buccal
complex cancer was the predominant cancer in I ndia, the incidence of tongue cancer is slowly incre
asing in our country as well.

ANATOMY
Oral tongue is an area limited posterio rly by circumvallate papillae (figure 1). These ca ncers are a distinct
clinical entity and must be differentiated from the cancers of the base of tongue. This write up is restricted to
the cancers arising in oral tongue. Most com mon site of involvement is lateral border of tongue accounting for
85% of cases. Dorsum, ventral surface and ti p of the tongue (5% each) form rest of the cases

Figure 1: Oral tongue boundaries and the most common sites of cancer

HISTOPATHOLOGY
The most common form of cancer on t ngue is squamous cell carcinoma, though there c ould tumor of
minor salivary gland, lymphomas and other rare malignancies.

HISTORY
Disease related information (onset, duration, pain, difficulty in swallowing, movement of t ongue, alteration in speech,
dental history etc.). History of habits and addictions, Medical and family history, including any prior malignancy,
Coexisting comorbidity, Prio r treatment with details examination Important points to consider are –

35
 EXAMINATION
Size, Location, Extent, Posteriorly -base of tongue / vallecula / tonsil involvement, Lateral/ deep extent of the
tumor, relationship to midline, mandible and hyoid, Ankyloglossia, Hypoglossal nerve palsy, Cervical
adenopathy (tongue has high propensity to contralateral metastasis particularly in larger tumors

BIOPSY
Biopsy of the lesion helps to confirm the presence of carcinoma and to know the histological type.
Assessment of grading is difficult and not mandatory on a biopsy specimen.Punch biopsy from most
representative area avoiding obviously necrotic areas. Incisional biopsy for submucosal
lesions/patch/verrucous lesions when punch biopsy is not feasible or non contributory

PRETREATMENT IMAGING
OPG-Limited role for evaluating bone erosion in tongue cancers due to low specificity owing to high
incidence of periodontitis and odontogenic infections in our population. At least 30% mineral loss is
required before bone erosion is detected. It is useful for planning mandibulotomy and for dental
treatment prior to radiotherapy.
High resolution Ultrasonography (USG) with guided FNAC- USG is performed real time with a 5- 10
MHz linear transducer and may be useful in evaluating the clinically negative neck for metastatic
nodes in early tongue cancers (where imaging may not be undertaken to evaluate the primary T1
lesions). It could be used to guide fine needle aspiration of suspicious nodes and can also influence
the extent of neck dissection by revealing extent of nodal disease. A meta-analysis revealed higher
sensitivity of USG as compared to CT and MRI for assessing metastatic neck nodes and showed
highest accuracy with USG guided FNAC. However this meta-analysis was performed in both N+ and
N0 necks and USG guided FNAC has reported lower accuracy in the N0 neck.

CT/MRI- Few studies exist comparing CT and MRI for imaging the oral cavity with emphasis on tongue
cancers. MRI is favoured over CT for T staging (better soft tissue delineation) particularly for tongue and
floor of mouth squamous cancers while CT and MRI were comparable for N staging. Diffusion weighted
MR imaging is evolving and is reported to be superior to conventional MRI for detecting metastatic
node51. A recent meta-analysis reported equivalence of CT, MRI and USG for neck nodes in the clinically
negative neck. Level of evidence (for MRI in T staging) - II and III Level of evidence (for equivalence of
USG, CT & MRI in N staging) - II; two meta-analyses. Helical CT /Multi-detector CT has the disadvantage of
insufficient soft tissue characterization for imaging the tongue and preferably to be used when MRI not
available. If CT is done then contrast enhanced CT is mandatory; performed after injection of 50-80 ml low
osmolar non-ionic iodine containing contrast; CT images to be viewed at high contrast settings. Multi-
detector CT with multiplanar reformations (at least 16 slice scanners) is preferred. If helical CT is used, 3
mm sections in soft tissue and bone algorithms are needed. Consensus Document for Management of
Tongue Cancer MDCT-Axial images are preferably to be viewed with coronal reformation to assess
extrinsic muscles and neurovascular bundle. Both soft tissue and bone algorithms are to be viewed along
with axial and coronal reformations to assess the mandible. CT is most specific modality for mandibular
erosion with high positive predictive value. However, mandibular invasion is infrequent in tongue cancers,
seen in < 10%, i.e. in advanced cancers or bulky tumors reaching or involving floor of mouth.
MRI (Multiplanar and gadolinium enhanced) Imaging method of choice due to superior soft tissue
characterization and when performed optimally provides accurate information regarding staging and
tumor thickness. MRI study is not optimal without post gadolinium scanning; the tumor-normal
tongue contrast is maximum on contrast enhanced T1W sequences that helps achieve accurate
staging. MRI is very sensitive for mandibular erosion and has high negative predictive value, but can
overestimate cortical erosion due to chemical shift artefacts. Nodal status is studied with a
combination of T2W, STIR and post-gadolinium sequences but adding diffusion weighted imaging (if
available) can increase accuracy of nodal status evaluation.

PETCT- PETCT is not routinely used in the initial workup for tongue cancers. It has an optional role for
evaluating distant metastases in stage III & IV tongue cancers particularly with large nodes in the lower neck. It
can depict the extent of nodal involvement in the N+ neck, but has no role in the evaluation of the N0 neck.

STAGING OF CARCINOMA TONGUE

We presently follow AJCC 7th edition for staging of tongue cancer which is same for all subsites of
oral cancer, however from 1st January 2018 we will be following AJCC 8th edition

36
DIFFERENTIATION
Grading
Grade I-well differentiated
Grade II-Moderately differentiated
Grade III-Poorly differentiated

TREATMENT
There are three main modality of treatm ent for any cancer broadly Surgical, Medical and Radiation
oncology. However as far as Head and neck Cancers are concerned the only two effective mo dalities for
curative treatment are Surgery and radiotherapy. Chemotherapy is only effective as adjuvant and
palliative setting for squamous cell carcinoma of head and n eck
Most important is to remember the general outline principle
Early stage (T1,T2, Node negative)
Surgery or RT( Sigle Modality trea tment)

Advance stage (T3,T4, Node positive )

Combined modality treatment
Surgery+Rt+/- Chemotherapy

SURGERY
Wide excision –The basic principle for surgery is wide excision of the tumor with 1cm margin. The
most important factor is wide excision margin. A margin of at least 5mm is must anything less t han
5mm is usually inadequate and may form a basis for a djuvant treatment.
37
 Surgical approaches - Most of the tongue cancers can be excised per orally i.e. approaching them
through the mouth. However some of them especially large and situated posteriorly may require
mandibulotomy, where in mandible is divided (Preserving the mental nerve) to reach to the posterior
surface of tongue. (Figure-2). Another approach is pull through where in a combined per oral and
neck approach is used (Figure 3).

Figure-2 Transoral approach Figure 3-Mandibulotomy approach

Reconstruction
Reconstruction Defect following excision of tongue cancers are usually reconstructed or closed primarily.
Leaving a defect raw is usually not advisable due to the risk of infection, pain and secondary
haemorrhage. However with the advent of CO2 laser, occasionally wounds are left open and defect
epithelizes. The following are the various options used for reconstruction in order of complexity
Primary closure
Skin graft
Local flap
Regional flap
Distant flap
Free flap

Primary closure
Small defects can be closed primarily. This is facilitated if excision is planned as a ‘V’shape. When
compromised in speech and function is anticipated, primary closure is avoided.

Local flaps
Inferiorly based nasolabial flaps are used in reconstruction of moderate sized tongue defects. The
flap is raised along the lateral aspect of the nasolabial skin fold on a subcutaneous pedicle that
contains offshoots from the facial artery and vein. Good colour match, proximity to the defect,
satisfactory contour and less donor site morbidity are the essential advantages of this flap69. 29
Consensus Document for Management of Tongue Cancer

Regional flap
Submental artery island flap is an option for select small to moderate size tongue defects70. However
flap necessitates the transfer of submental skin into the oral cavity and usually is not advisable due to
hair growth in male patients. Moreover it may compromise nodal clearance while harvesting the flap.

Distant flap
Pectoralis major myocutaneous flap (PMMC) is the most frequently used myo-cutaneous flap for large defects
especially when a portion of the adjacent lateral segment of the mandible also needs to be resected

Free flap
Free flap Radial forearm artery flap (FRAFF) is used for partial tongue defect, anterolateral
thigh(ALT) flap for full tongue defects and free fibula osteo-cutaneous flap (FFOCF) is used when
bone is excised72. Other options include parascapular flap and lateral arm flap.

Inoperable disease
Criteria for inoperability are few in tongue cancer, but in India due to various socioeconomic
conditions one tends to see tumours that due to their local spread are outside the realm of curative
surgery. Few examples of such conditions would be, skin involvement, severe ankyloglossia with
tumor involvement of the base of tongue, Extensive tumor involving almost whole of tongue, etc. Such
tumors are usually treated by Chemotherapy and radiation and are seldom curable.

Metastatic Disease
Although oral cancers can spread to various parts of body, lungs are the most common site of metastasis,
followed by the bones. The usual treatment is Chemotherapy with palliative intent and the life span is limited.

38
 ACHALASIA CARDIA
-Dr. Lalit Aggarwal

Achalasia is a disease of unknown cause characterized manometrically by absent esophageal body

peristalsis and abnormally high LES resting pressure or incomplete relaxation of the LES. Histological
findings in the dorsal motor nucleus, vagus nerve, and myenteric plexus suggests process causing
smooth muscle denervation.
Sir Thomas Willis provided the first documented case report of achalasia in 1674, when he described his
experience with esophageal dilation with whalebone in a patient who had dysphagia and a dilated esophagus. In
1927, Hurst coined the term esophageal achalasia, meaning absence of relaxation. It is widely accepted that the
partial or total absence of swallow-induced LES relaxation (the main functional anomaly in achalasia) is caused by
a loss of the inhibitory innervations in the myenteric plexus; the exact mechanism behind this loss of inhibitory
neurons is far from clear, and the treatment is still limited to mechanical or surgical disruption of the LES.
Although complete absence of peristalsis in the esophageal body has been proposed as the major abnormality,
present evidence indicates achalasia is a primary disorder of the LES. This is based on 24-houroutpatient
esophageal motility monitoring, which shows that, even in advanced disease, up to 5% of contractions can be
peristaltic. The observation that esophageal peristalsis can return in patients with classic achalasia following
dilation or myotomy provides further support that achalasia is a primary disease of the LES. Motility disorders are
classified as either primary or secondary. This distinction is based on whether the esophagus is primarily involved
or whether the esophageal involvement is part of a systemic process.

Esophageal motility disorders

Primary esophageal motility disorder Secondary esophageal motility disorders

Achalasia,
“Vigorous” achalasia
Diffuse and segmental esophageal spasm
Nutcracker esophagus
Hypertensive lower esophageal sphincter
Nonspecific esophageal motility disorders
Collagen vascular diseases:
Progressive systemic sclerosis,
Polymyositis,
Dermatomyositis,
Mixed connective tissue disease,
SLE
Chronic idiopathic intestinal pseudo-obstruction
Neuromuscular diseases
Endocrine and metastatic disorders

Pathogenesis
The pathogenesis of achalasia is presumed to be a neurogenic degeneration, which is either idiopathic or
due to infection. In experimental animals, the disease has been reproduced by destruction of the nucleus
ambiguus and the dorsal motor nucleus of the vagus nerve. In patients with the disease, degenerative
changes have been shown in the vagus nerve and in the ganglia in the myenteric plexus of the esophagus
itself. This degeneration results in hypertension of the LES, a failure of the sphincter to relax on swallowing,
elevation of intra-luminal esophageal pressure, esophageal dilatation, and a subsequent loss of progressive
peristalsis in the body of the esophagus. The esophageal dilatation results from the combination of a non-
relaxing sphincter, which causes a functional retention of ingested material in the esophagus, and elevation
of intraluminal pressure from repetitive pharyngeal air swallowing with time, the functional disorder results
in anatomic alterations seen on radiographic studies, such as a dilated esophagus with a tapering, “bird’s
beak”-like narrowing of the distal end. There is usually an air-fluid level in the esophagus from the retained
food and saliva, the height of which reflects the degree of resistance imposed by the non-relaxing sphincter.
As the disease progresses, the esophagus becomes massively dilated and tortuous.

Vigorous Achalasia
A subgroup of patients with otherwise typical features of classic achalasia has simultaneous
contractions of their esophageal body that can be of high amplitude. This manometric pattern has
been termed vigorous achalasia, and chest pain episodes are a common finding in these patients.
Since the development of high resolution esophageal manometry technology, the term vigorous
achalasia has been replaced with Chicago type 3 achalasia.

Types of ACHALASIA:
The Chicago classification is a currently accepted system that separates classic achalasia into 3
clinically relevant subtypes.
The manometric findings common to all types of achalasia include impaired relaxation of the
LES (residual pressure or integrated relaxation pressure of ≥10 mmHg) and absent peristalsis in
a patient without mechanical obstruction near the LES.
39
 Type I has 100% absent peristalsis and no significant esophageal pressurization.
Type II has 100% absent peristalsis with ≥20% of swallows with pan-esophageal pressurization
to >30 mmHg.
Type III has ≥20% of swallows with premature spastic contractions (distal latency of <4.5 s).

Pseudoachalasia:
Pseudoachalasia may result from malignancies at the GEJ that infiltrate the submucosa. Associated
aperistalsis of the esophageal body and narrowing of the GEJ simulate the findings of classic achalasia. In
many cases, no mucosal lesion is visible endoscopically, and the diagnosis is suspected only because o1f
the older age of the patient and the recent onset of dysphagia. Length of the “bird’s beak” is greater in
patients with pseudoachalasia associated with malignancy than in those with classic achalasia.

Epidemiology
The worldwide prevalence of achalasia is estimated at less than 10 per 100,000 persons per year.
Hospitalizations for achalasia increase in frequency with age, with a peak incidence in the 65- to 84-
year-old age group.3 in the largest study of untreated patients with achalasia published to date, the
median age at diagnosis was 49 years.
Men and women are equally affected, with no ethnic predisposition to the disease. Although there
have been reports of “familial achalasia,” familial association has not been supported by
epidemiologic studies, and the disease does not seem to follow any mendelian inheritance pattern.
The triple-A syndrome, or Allgrove disease, is a rare condition consisting of achalasia, alacrimia and
adreno-cortico tropic hormone (ACTH)–resistant adrenal insufficiency. Severe skeletal and autonomic
neuropathy, cerebellar dysfunction, and cognitive defects are also part of the syndrome. The disease
almost always occurs in the first decade of life, and dysphagia is an early symptom. Most children
have hypoglycemic or hypotensive episodes from adrenal insufficiency. Neurologic deterioration
commonly occurs in the second or third decade of life. The syndrome follows an autosomal recessive
inheritance pattern with variable penetrance. Agenetic linkage analysis of families with triple-A
syndrome has linked the disease to markers on 12q13, and recently, mutations have been localized to
the AAAS gene. Although achalasia significantly increases the risk for esophageal cancer and other
complications, longitudinal studies indicate that achalasia does not affect life expectancy.

Symptoms
The cardinal symptom of achalasia is dysphagia, which is present in almost all patients at the time of
diagnosis. Most patients have had symptoms for more than 5 years before the diagnosis of achalasia
is made and typically accommodate to their dysphagia by eating smaller quantities of food, avoiding
solid food such as meat, bread, and drinking liquids with their meals.
Often, patients are incorrectly given another diagnosis, most commonly gastro esophageal reflux
disease (GERD), before eventually undergoing esophageal function tests that document achalasia. As
the esophagus dilates, it becomes a reservoir of undigested food, and in severe cases it empties only
when sufficient hydrostatic pressure is generated. Because of stasis in the esophagus, regurgitation
occurs in 76% of patients, and 52% complain of heartburn.
Heartburn is due to stasis and fermentation of the food, and halitosis is a common complaint.
Aspiration occurs usually at night when the patient is recumbent and can cause nocturnal cough,
pneumonia, and pulmonary abscess.
Chest pain is present in 41% of untreated patients in the series, even though it was never considered
the main complaint. The pain is probably due to esophageal wall distention, stasis esophagitis, or
Candida esophagitis. Contrary to common belief, it is not related to younger age, shorter duration of
symptoms, or the manometric finding of vigorous achalasia.
Weight loss was present in 35% of patients with achalasia in the series. It is usually due to inability of the
esophagus to empty and to sitophobia, or fear of eating. The average weight loss was 20 lb. Twenty percent
of patients lost 1 to 15 lb, 7% lost 16 to 30 lb, and 8%lost more than 30 lb.4 Severe weight loss over a short
period in elderly patients should raise the suspicion ofmalignancy-induced or secondary achalasia.

Differential diagnosis
Esophageal carcinoma
Esophageal stricture
Gastric carcinoma
Non–small cell lung cancer
Thoracic scleroderma
Amyloidosis
Chagas disease
Collagen-vascular
disease Lymphoma

40
Diagnosis

X-RAY
Visualization of the anatomical structure of the esophagus can be done by using a chest X-ray. The
test reveals a dilated esophagus behind the sternum with a narrow end similar to a bird’s beak.
Examiners may spot a few gastric bubbles although most are minute or hardly visible.
BARIUM SWALLOW
Features of achalasia depicted at barium study under fluoroscopic guidance include the following:
Failure of peristalsis to clear the esophagus of barium with the patient in the recumbent position
Antegrade and retrograde motion of barium in the esophagus secondary to uncoordinated, non
propulsive, tertiary contractions
Pooling or stasis of barium in the esophagus when the esophagus has become atonic or non
contractile (which occurs late in the course of disease)
LES relaxation that is incomplete and not coordinated with esophageal contraction
Dilation of the esophageal body, which is typically maximal in the distal esophagus
Tapering of the barium column at the un-relaxed LES, resulting in the bird beak sign

ESOPHAGEAL MANOMETRY
It is perhaps the best method for evaluating the esophagus in case of persistent regurgitation of stomach
acids. The main goal of this clinical procedure is to measure the pressure generated by the contracting
esophageal muscles. Here, a flexible plastic tube is passed through the nostrils, down the back of the throat
and finally into the esophagus as the patient swallows. Affected patients absolutely show no muscular
contractions in the lower half of the esophagus, indicating the inefficiency of the lower sphincter to relax.
The LES pressure remains elevated even on swallowing and do not undergo any significant reduction.

MANOMETRIC CHARACTERISTICS OF THE PRIMARY ESOPHAGEAL MOTILITY DISORDERS

1. Achalasia
Incomplete lower esophageal sphincter (LES) relaxation ( 75%
relaxation) Aperistalsis in the esophageal body
Elevated LES pressure ≤26 mmHg
Increased intra esophageal baseline pressures relative to gastric baseline

2. Diffuse esophageal spasm (DES)

Simultaneous (nonperistaltic contractions) ( 20% of wet
swallows) Repetitive and multipeaked contractions
Spontaneous contractions
Intermittent normal peristalsis
Contractions may be of increased amplitude and duration

3. Nutcracker esophagus
Mean peristaltic amplitude (10 wet swallows) in distal esophagus≥180
mmHg Increased mean duration of contractions ( 7.0 s)
Normal peristaltic sequence

Hypertensive lower esophageal sphincter

Elevated LES pressure (≥26
mmHg) Normal LES relaxation
Normal peristalsis in the esophageal body

Ineffective esophageal motility disorders

Decreased or absent amplitude of esophageal peristalsis ( 30
mmHg) Increased number of nontransmitted contractions
41
ENDOOSCOPY
An upper GI esophagram should first be performed to assess the anatomy. It is a common element
used early in the workup of dysphagia and is a good screening tool. Particular attention to the
morphology of the esophagus (i.e., is a sigmoid esophagus present?) and anatomic location of the
LES should be given attention. Classical findings on barium esophagraminclude distal tapering to the
GE junction, resulting in a “bird’s beak” appearance. Any abnormalities should be biopsied to rule out
causes of pseudoachalasia, as well as evaluated with CT and/or endoscopic ultrasound.

ESOPHAGEAL PH MONITORING
The technique enables physicians to measure the reflux of acid from the stomach into the esophagus. To
perform this, a thin plastic catheter is inserted into the esophagus as the patient swallows. The presence of
acid in this region of the gastrointestinal tract can be detected with a sensor fixed at the tip of the catheter.

COMPUTED TOMOGRAPHY
Computed tomography (CT) scanning with oral contrast enhancement may demonstrate the gross
structural esophageal abnormalities associated with achalasia, especially dilatation, which is seen in
advanced stages. However, CT findings are nonspecific, and the diagnosis of achalasia cannot be
made using CT alone. CT scanning may be indicated in the workup of patients with suspected
pseudoachalasia. CT findings should always be confirmed by means of barium swallow study with
fluoroscopy, upper gastrointestinal endoscopy, and esophageal manometry.
ULTRASONOGRAPHY
Ultrasonography is not useful in establishing the primary diagnosis of achalasia. [21]However, Eckhardt et al
investigated its utility in the differentiation of true achalasia from pseudoachalasia. [22] The authors performed
transabdominal ultrasonography in subjects with achalasia (n = 28), in those with pseudoachalasia.

EUS
EUS findings in achalasia are controversial. Some authors report thickened esophageal wall in most
patients examined. The main role of EUS in achalasia is to exclude other mural abnormalities.

BIOPSY
Biopsy, the removal of a tissue sample during endoscopy, is not typically necessary in achalasia but if
performed shows hypertrophied musculature and absence of certain nerve cells of the myenteric
plexus, a network of nerve fibers that controls esophageal peristalsis.[12]
TREATMENT
Therapy for achalasia is palliative in nature and may involve pharmacologic, endoscopic, and surgical
therapies. It must be emphasized to the patient that therapies do not cure or address the
pathophysiologic abnormality, but instead they are designed to relieve symptoms of obstruction and
impaired esophageal emptying by relaxing or disrupting the muscle fibers of the LES.

LIFESTYLE CHANGES
Both before and after treatment, achalasia patients may need to eat slowly, chew very well, drink plenty of
water with meals, and avoid eating near bedtime. Raising the head off the bed or sleeping with a wedge
pillow promotes emptying of the esophagus by gravity. After surgery or pneumatic dilatation, proton pump
inhibitors are required to prevent reflux damage by inhibiting gastric acid secretion, and foods that can
aggravate reflux, including ketchup, citrus, chocolate, alcohol, and caffeine, may need to be avoided.

MEDICAL TREATMENT
Medical therapy has focused on drugs that relax smooth muscle and decrease LES pressure. Nitrates and calcium
channel blockers are used. Because of their limited effectiveness and inconsistent absorption, their use is limited.
Impaired esophageal emptying can affect their ingestion and absorption. In randomized controlled trials, calcium
channel blockers have not shown significant success in improving clinical symptoms, despite lowering LES
pressures. Sildenafil, a phosphodiesterase inhibitor, has been shown to have potent relaxing effects on the LES,
but its clinical use is limited by poor tolerance and side effects. Nitrates, which can be used in sublingual
formulation to overcome poor absorption, tend to work better than calcium channel blockers for symptom relief.
Their use, however, can lead to undesired side effects such as hypotension and headache and, like all medical
therapies, their efficacy decreases with time. Pharmacologic therapy should be pursued only in patients who, for
medical reasons, are unable to undergo other therapies.

ENDOSCOPIC TREATMENT
Endoscopic therapies include balloon dilation and botulinum toxin injection. Botulinum toxin injection
works by inhibiting acetylcholine release at cholinergic nerve endings, thereby decreasing LES pressure. A
recent meta-analysis of therapies for achalasia, by Campos et al, reviewed 315 patients in 9 studies, who
underwent botulinum toxin injection and found initial symptom relief of 78.7% at 1month post-procedure,
which steadily declined over time to 40.6% at 12 months, with 46.6% of patients requiring repeat injection. 54

42
While botulinum toxin injection therapy may provide temporary relief of symptoms, its effects are not durable as
with surgery and repeat treatments are often needed. Moreover, when compared with myotomy, the results for
botulinum toxin seem inferior. Zaninotto et al, in a randomized trial comparing botulinum toxin injection with
laparoscopic Heller myotomy with fundoplication, observed at 1 year 60% remained asymptomatic in the
botulinum injection arm compared with 87% of patients in the surgical arm being symptom free. At 2 years, only
34% of patients in the botulinum injection arm remained without symptoms, while 87% in the surgical arm
remained symptom free.55 Multiple injections can further complicate future surgical therapy due to the
submucosal fibrosis that can result, making myotomy more difficult and increasing the risk of perforation.56
Endoscopic botulinum toxin injection may serve as an alternative to those unwilling or unable to undergo more
invasive procedures but has a limited role in the treatment of the disease.

There is lively debate regarding the most effective treatment for long-term symptom relief. The relative rarity
of achalasia means that most patients will be treated according to local preferences and expertise. First-line
achalasia treatment has traditionally been pneumatic dilation, reserving surgery for patients requiring
repeated dilations or when the former treatment fails.4 Botulinum toxin injections in the LES have recently
been shown to provide effective dysphagia relief, but their effect is short lived.
Nowadays, minimally invasive surgery—with its more limited surgical morbidity—seems to have completely
changed the treatment algorithm, and laparoscopic Heller myotomy with partial fundoplication is preferred
by most gastroenterologists and surgeons as the primary treatment for achalasia.

MEDICAL TREATMENT
Calcium channel blockers and nitrates are used to decrease LES pressure. Approximately 10% of
patients benefit from this treatment. This treatment is used primarily in elderly patients who have
contraindications to either pneumatic dilatation or surgery.
Endoscopic treatment includes an intra-sphincteric injection of botulinum toxin to block the release of
acetylcholine at the level of the LES, thereby restoring the balance between excitatory and inhibitory
neurotransmitters. [15] This treatment has limited value. Only 30% of patients treated endoscopically still
have relief of dysphagia 1 year after treatment. Most patients need repeated botulinum toxin injections, with
short-lasting clinical benefits. This treatment can cause an inflammatory reaction at the level of the gastro
esophageal junction, making a subsequent myotomy very difficult. Compared with pneumatic dilation,
botulinum toxin injection is associated with significantly higher symptom recurrence rates at 12 months. [16]
Similarly, this treatment modality is less effective than laparoscopic Heller myotomy at 2-year follow-up. [17]
Use this treatment in elderly patients who are poor candidates for dilatation or surgery.
Pneumatic dilatation performed by a qualified gastroenterologist is the recommended treatment in
those sporadic cases in which surgery is not appropriate. [18] A balloon is inflated at the level of the
gastro esophageal junction to blindly rupture the muscle fibers while leaving the mucosa intact. The
success rate is 70-80%, and the perforation rate is approximately 5%.

SURGICAL TREATMENT
LAPAROSCOPIC HELLER MYOTOMY
The operation is performed under general anesthesia and oro-tracheal intubation. The patient is
placed supine on the operating table with legs abducted on flat padded leg boards to minimize the risk
of lower extremity neurovascular injury. The right arm is tucked against the patient’s side, and the left
arm remains on an arm board.
The first 12-mm blunt trocar used for the laparoscope is inserted along the midline, halfway between the
umbilicus and the xiphoid (Figure. A 5-mm trocar is inserted as laterally as possible on the patient’s right
side, immediately below the costal margin, to lift the left liver lobe. A 5 mm trocar inserted immediately
below the xiphoid is used for the operator’s left hand, while a 12-mm trocar inserted laterally below the left
costal margin provides access for the surgeon’s right hand. Finally, a 5-mm trocar a little above the
umbilicus on the mid-clavicular line is used to pull down the gastric fundus.

An assistant on the surgeon’s left-hand side lifts the left liver lobe using an atraumatic retractor, thus
exposing the cardia region. There is no need to divide the left triangular ligament. An assistant on the
surgeon’s right hand side grasps the gastric fundus with atraumatic forceps, maintaining a caudal
traction on the esophago-gastric junction.

43
The operation begins with a minimal dissection of the anterior part of the esophagus. With the cautery hook,
the peritoneum over the esophago-gastric junction is divided to expose the anterior wall of the esophagus.
Any adipose tissue (usually found at thislevel) is removed, paying attention to the small vessels coming
from the gastric wall, which should be coagulated with the bipolar forceps; they usually mark the inferior
limit of the myotomy. The left vagus nerve (which becomes anterior at this level where it crosses the
anterior esophageal wall from left to right) is clearly evident and must not be damaged.

Figure-2: During the myotomy, the anterior Figure-3: The intraoperative use of a Rigiflex 3.0 cm
vagus nerve must be identified and preserved balloon, gently inflated and deflated, facilitates the
from damage myotomy by exposing the circular fibers, which can
then be stretched, and easily cut or torn apart.

The myotomy is started with the cautery hook on the dilated part of the distal esophagus, above the lower
esophageal sphincter that, in cases of long-standing achalasia,is often marked by a whitish, sclerotic area. The
myotomy must be started 2 cm above the esophago-gastric junction to expose the esophageal submucosal layer
with the least risk of perforation. The cautery power is reduced to 15 W to avoid transmitting its coagulating effect
to the underlying mucosa. First the longitudinal muscle fibers are hooked, lifted, and coagulated, until the circular
fibers are exposed; then the latter are hooked, lifted, and divided in the same way. The submucosal layer, which
forms a slight bulge between the two margins of the myotomy, is then exposed and, using the forceps in the left
hand, the margin of the myotomy is delicately lifted, while small scissors are used to bluntly dissect the muscle
layer from the submucosal layer. The muscle tissue is then cut, and minor bleeding from the edges of the
myotomy can be controlled with a careful use of the cauterized scissors, or simply with the aid of mechanical
compression using a small sponge. A 6 to8-cm-long myotomy is performed, extending it on the gastric side to 1.5
to 2 cm below the oblique muscle fibers, representing the beginning of the gastric muscle and thus exposing the
gastric submucosa, which is usually more vascularized than the esophageal mucosa. Scissors are used in the
proximal part, and a hook cautery is inserted downward on the gastric side to lift and divide the circular muscle
fibers.

.
Care must be taken during the myotomy to avoid injuring the anterior vagus nerve and to prevent any
esophageal perforation or spiraling of the myotomy. A feature of our favored technique involves the intra-
operative use of a 30-mm Rigiflex balloon. The balloon is placed inside the esophageal cavity at the cardia
level using an endoscopically positioned guide wire. During the myotomy, the balloon is gently inflated and
deflated with 30 to 50 cc of air using a syringe: This exposes the circular fibers so that they can be
stretched and easily cut or torn apart. The edges of the myotomy are separated and peeled away from the
submucosal plane. Any minimal bleeding from submucosal vessels is easily controlled by inflating the
balloon thus reducing the need to use the cautery. A fundoplication is normally added toprevent
postoperative gastro esophageal reflux disease (GERD), which may be a severe complication in patients
with a poor esophageal clearance caused by aperistalsis. Given the esophageal body’s lack of propulsive
peristaltic activity, a partial fundoplication is usually performed either anteriorly or posteriorly; the former
has the advantage of protecting the exposed esophageal mucosa and can be performed without completely
mobilizing the esophagus, thus preserving the natural anti-reflux mechanisms.

COMPLICATION
The main risk relating to esophageal myotomy is a mucosal injury (perforation).Esophageal perforation is
infrequent during laparoscopic Heller myotomy (<4% in our series and rarely >6% in the literature)

44
ADEQUACY OF MYOTOMY
The purpose of surgical myotomy is to disrupt the LES fibers and relieve dysphagia symptoms, but how far
the myotomy should extend has been a point of controversy. When the myotomy was performed via a
transthoracic approach, it was extended just across the G-E junction. Since the advent of laparoscopy, most
surgeons extend the myotomy 1 to 2 cm onto the gastric wall, which seems to be fundamental to ultimate
successful outcome. A recent study conducted by Oelschlager et al at the University of Washington claimed
that an extended myotomy (>3 cm) provides better symptomatic dysphagia relief than a standard 2-cm
myotomy. These authors extended the Heller myotomy 3 cm down from the external G-E junction and
performed a Toupet posterior 270 degree fundoplication to prevent postoperative GER.

ENDOSCOPIC PNEUMATIC DILATION

Pneumatic dilation aims to disrupt the LES by forcefully dilating it with an air-filled balloon. To date,
the most commonly used is the Rigiflex balloon, which is available in three sizes (30, 35, and 40 mm in
diameter).the balloon is inserted over an endoscopically maneuvered guide wire, positioned across
the LES and inflated under endoscopic visualization. The immediate success rate of this procedure is
55% to 70% with a single dilation but this figure can be increased to 90% with multiple dilations.
Esophageal perforation is the most important and potentially life-threatening complication following
pneumatic dilation, occurring mainly above the cardia on the left side of the esophagus. The
perforation rate using the Rigiflex dilator ranges from 0% to 6.6%.Other potential complications
following pneumatic dilation include prolonged pain, GER, aspiration pneumonia, gastrointestinal
hemorrhage, esophageal mucosal tears without perforation, and intramural esophageal hematoma.

OPEN ESOPHAGEAL MYOTOMY

Open techniques of distal esophageal myotomy are rarely used outside reoperations. In fact, primary
procedures can almost always be successfully completed via laparoscopy. A modified Heller myotomy can
be performed through a left thoracotomy incision in the sixth intercostal space along the upper border of
the seventh rib. A myotomy through all muscle layers is performed, extending distally over the stomach to 1
to 2 cm below the junction, and proximally on the esophagus for 4 to 5 cm. The cardia is reconstructed by
suturing the tongue of gastric fundus to the margins of the myotomy, to prevent rehealing of the myotomy
site, and to provide reflux protection in the area of the divided sphincter.

SURGERY OR PNEUMATIC DILATION?

After a median follow up of approximately 5 years, 65% of patients treated with pneumatic dilation reported
good symptom control as compared with 95% of patients who had undergone surgery. Compared with
pneumatic dilatation, laparoscopic Heller myotomy is associated with better results in terms of dysphagia
improvement and postoperative gastro esophageal reflux rates, with a significantly lower risk of re-intervention.
[37]
Although the results are similar at a short-term follow-up, [38] long-term follow-up shows that most
patients after surgery are asymptomatic, compared with only 50% of patients even after multiple
pneumatic dilatations.

Per-oral endoscopic myotomy (POEM)

Per-oral endoscopic myotomy (POEM) has been introduced relatively recently as a novel approach to achalasia.
[20, 21]
This procedure is performed under general anesthesia with endotracheal intubation. A 2-cm longitudinal
mucosal incision is made on the mucosal surface to create a mucosal entry to the submucosal space. An anterior
submucosal tunnel is created downwards, passing the gastro esophageal junction and about 3 cm into the
proximal stomach. Once the submucosal tunnel is completed, section of the circular muscle fibers begins 2-3 cm
distal to the mucosal entry, approximately 7 cm above the gastro esophageal junction. The myotomy is continued
step by step distally until the gastric submucosa is reached, extending approximately 2-3 cm distal to the gastro
esophageal junction. After identification and section of the circular muscle fibers of the lower esophagus and
proximal stomach, the mucosal entry site is closed with hemostatic clips.
Several potential advantages of POEM compared with laparoscopic Heller myotomy have been proposed.
The endoscopic approach should theoretically minimize postoperative pain. A longer myotomy can be
performed, extending to the medium third of the esophagus, just below the aortic arch. A concomitant anti-
reflux surgery may not be required because of the selective section of the circular muscle fibers without any
dissection at the level of the gastro-esophageal junction. In current practice, few data are available
regarding clinical outcomes in small series of patients over very short follow-up periods.

ESOPHAGEAL RESECTION FOR END-STAGEMOTOR DISORDERS OF THE ESOPHAGUS

Patients with dysphagia and long-standing benign disease whose esophageal function has been destroyed
by the disease process or multiple previous surgical procedures, are best managed by esophagectomy.
Fibrosis of the esophagus and cardia can result in weak contractions and failure of the distal esophageal
sphincter to relax. The loss of esophageal contractions can result in the stasis of food, esophageal
dilatation, regurgitation, and aspiration. The presence of these abnormalities signals end-stage motor
disease. In these situations esophageal replacement is usually required to establish normal alimentation.
Before proceeding with esophageal resection for patients with end-stage benign disease, the choice of the
organ to substitute for the esophagus (i.e., stomach, jejunum, or colon) should be considered.
45
The choice of replacement is affected by a number of factors, as described later in the section on
Techniques of Esophageal Reconstruction. If minimally invasive esophagectomy is to be performed,
thoracoscopic dissection should be combined with abdominal dissection. Attempts at MIS trans-hiatal
esophagectomy for the massively dilated esophagus may result in large volume bleeding from
mediastinal vessels that become enlarged with esophageal dilation, and must be directly controlled
for hemostasis to be adequate, and the operation to be safe
CONCLUSIONS
Surgical myotomy is an effective and durable treatment for achalasia and, because laparoscopy has reduced the
related morbidity, laparoscopic Heller myotomy has become the first-line treatment. A partial fundoplication
should be performed in conjunction with the myotomy to minimize the risk of postoperative GERD.

PRIMARY HYPERPARATHYROIDISM

-Dr. Vivek Aggarwal

Introduction
Parathyroid hormone is the chief regulator of calcium homeostasis in the human body. Primary
hyperparathyroidism (PHPT) results from inappropriate overproduction of parathyroid hormone from one or many
parathyroid gland(s) and presents with hypercalcemia. It is the third most common endocrine disorder affecting
0.3% of the general population, 1%–3% of postmenopausal women and a total population incidence of 21.6 cases
per 100,000 person years [1–3]. PHPT usually occurs as the result of sporadic parathyroid adenomas or
carcinomas but can also be seen in association with multiple endocrine neoplasias and in rare genetic syndromes
and metabolic diseases [4]. The most common cause is parathyroid adenoma, usually due to single gland disease
but familial disorders may be associated with multigland disease. Secondary hyperparathyroidism occurs as a
normal response to hypocalcemia due to diseases affecting the kidney (such as renal tubular acidosis), liver,
intestines, and vitamin D deficiency. Tertiary hyperparathyroidism occurs in patients with long-standing
secondary hyperparathyroidism who develop autonomous PTH production with hypercalcemia. The most common
situation resulting in tertiary hyperparathyroidism is the patient with secondary hyperparathyroidism with renal
failure who then receives a renal allograft [5–13].

Physiology of Calcium Regulation

Parathyroid hormone increases receptor mediated tubular re-absorption of calcium in the kidney,
stimulates release of skeletal calcium stores, up-regulates 1- α- hydroxylase leading to increased
1,25-dihydroxy-vitamin D production and increased calcium re-absorption from the gastrointestinal
tract [14]. Central to calcium regulation is the calcium-sensing receptor (CaSR) found primarily in the
chief cells of the parathyroid glands [15]. The CaSR responds to the level of ionized calcium in the
extracellular space and can upregulate or downregulate the secretion of parathyroid hormone.
Diagnosis of Primary Hyperparathyroidism
Primary hyperparathyroidism is diagnosed when PTH is inappropriately elevated, in the context of serum calcium
levels. Biochemical measurement of PTH [1–84], widely called the “bioactive” or “3rd-generation assays”are
considered the most precise method for measuring biologically active PTH using methods such as a two-site
IRMA, a chemiluminescent enzymatic assay, or enzymelinked immunosorbent assay (ELISA) [16–19].

Etiology/Epidemiology of Primary Hyperparathyroidism

Most patients with PHPT have a single adenoma (∼80% of cases), but multigland disease can occur in
10%– 15% of cases and double adenomas in 4%-5% [20]. Parathyroid carcinoma is a rare cause
(usually less than 1% of patients)of hyperparathyroidism [21, 22].
Genetic Causes of Primary Hyperparathyroidism

46
Clinical Presentation
Prior to the 1970s,when automated screening panel for PTH was introduced, this was a disease of recurrent kidney
stones, osteitis fibrosa cystica, neuromuscular dysfunction characterized by type II muscle cell atrophy
and symptomatic hypercalcemia, it has now become an asymptomatic or mildly symptomatic
disease detected by the incidental finding of hypercalcemia [23] Less specific features of primary
hyperparathyroidism include fatigue, muscle weakness, mild cognitive disturbances, hypertension,
left ventricular hypertrophy, valvular calcification, and cardiovascular mortality.
Management of Primary Hyperparathyroidism
Surgery: The only cure for primary hyperparathyroidism due to parathyroid adenomas is
surgicalresection of the culprit gland or glands. Indications for surgery in asymptomatic patients—
these include age less than 50 years, serum calcium 0.25mmol/L above the upper limit of normal,
creatinine clearance <60mL/min, DXA t-score <- 2.5 at any site, and/or previous fragility fracture [24].
Bilateral neck exploration with direct visualization and identification of all abnormal parathyroid glands with
subsequent removal was previously considered the gold standard of care. Experienced surgeons reported
to be able to identify affected glands in 95% of case. The new standard for most surgeons is preoperative
radiologic localization of adenomas to direct a focused parathyroidectomy using unilateral neck exploration
and adjunctive intraoperative PTH. Intraoperative hand held gamma probe identification of in situ and
resected radiolabelled hyperplastic parathyroid glands can be helpful. Subtotal parathyroidectomy (3&1/2)
or total excision with autotransplantation is recommended for multi-glandular disease. At exploration, all
glands should be visualized and those normal glands to remain in situ should be marked for later
localization. If one or two normalglands are found, then only the hyperplastic glands should be removed. If
all glands are hyperplastic, total parathyroidectomy and immediate autotransplantation will obviate the need
to subsequently explore a neck scarred from previous surgery. Generally, the thymus is also removed
because of the possible presence of diseased supernumerary glands within it. A minority of MEN2 patients
develop hyperparathyroidismwhich, when present, is characteristically mild. At total thyroidectomy for
medullary carcinoma, only hypertrophied parathyroid glands should be removed after all are identified and
marked [25]. Complications from surgery for parathyroidectomy include persistent hyperparathyroidism if
insufficient disease causing tissue is removed recurrent laryngeal nerve injury, hematoma, infection,
transient or permanent postoperative hypocalcemia, and seizures from hypocalcemia.
Localisation of Hypersecreting ParathyroidGlands.Preoperative imaging is needed if the surgeon is
planning minimally invasive parathyroidectomy, where only one side of the neck is exposed. Preoperative
imaging can also be helpful in patients with previous neck surgery in whom scar tissue can make direct
visualization more challenging. Of the available imaging techniques, the most successful modality is the
99technetium-labelled sestamibi-single photon emission CT identifying up to 89% of single parathyroid
adenomas [26, 27]. 99Technetium-labelled sestamibi (99mTc MIBI) is taken up by parathyroid and thyroid
tissue. Uptake is enhanced and prolonged in adenomatous and hyperplastic parathyroids [91]. Ultrasound
is the second most useful modality and when used with 99mTc MIBI preoperatively can enhance adenoma
detection rates. 4D CT scan and choline labeled PET scan are showing promising results.

Revision Surgery-About 5% of patients undergoing parathyroidectomy will exhibit persistent

hypercalcemia because of insufficient removal of disease-causing tissue. The localization of
persistent disease can be anticipated based upon verification of the diagnosis, reviewing pathology
slides and operative reports, interviewing previous surgeons and by adding localization procedures to
those previously mentioned [28]. Gadolinium-enhanced magnetic resonance MRI, CT with intravenous
contrast, angiography, and selective venous sampling for PTH can aid with localization. Most missed
glands are found in the neck. Some surgeons enter the operative site lateral to the strap muscles but
medial to the sternocleidomastoid muscle and great neck vessels to avoid a scarred midline field [29].
Upper mediastinal locations may be approached via an upper-third median sternotomy or by video-
assisted thoracic surgery (VATS). If repeat operation is unsuccessful, observation and pulsed
localization testing may allow detection as hyperfunctioning parathyroid tissue enlarges.
Conclusion
Primary hyperparathyroidism is one of the most common endocrinological disorders. In rare
circumstances, primary hyperparathyroidism is associated with several familial syndromes. Primary
hyperparathyroidism is most frequentlyidentified incidentally on automated multichannel blood
screening panels and is very often asymptomatic at the timeof diagnosis. Parathyroidectomy remains
the definitive cure for the disease, and some controversy surrounds the optimal surgical technique for
the procedure. Medical therapy with the goal of bone preservation is an option for patients without
symptoms, and calcimimetics effectively normalize calcium levels but have specific indications for
use. Medical therapy may be tried for patients with hypercalcemia who cannot undergo surgery.
References
R. A. Wermers, S. Khosla, E. J. Atkinson et al., “Incidence of primary hyperparathyroidism in Rochester, Minnesota, 1993– 2001: an
update on the changing epidemiology of the disease,”Journal of Bone and Mineral Research, vol. 21, no. 1, pp. 171–177, 2006.

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 R. Mihai, J. A. Wass, and G. P. Sadler, “Asymptomatic hyperparathyroidism—need for multicentre studies,”
ClinicalEndocrinology, vol. 68, no. 2, pp. 155–164, 2008.
L. J. Melton Jr., “The epidemiology of primary hyperparathyroidism in North America,” Journal of Bone and MineralResearch,
vol. 17, supplement 2, pp. N12–N17, 2002.
S. Unger, D. A. Paul, M. C. Nino et al., “Mucolipidosis II presenting as severe neonatal hyperparathyroidism,” EuropeanJournal
of Pediatrics, vol. 164, no. 4, pp. 236–243, 2005.
J. George, S. V. Acharya, T. R. Bandgar, P. S. Menon, and N. S. Shah, “Primary hyperparathyroidism in children and
adolescents,” Indian Journal of Pediatrics, vol. 77, no. 2, pp. 175–178, 2010.
E. T. Durkin, P.F.Nichol,D. P.Lund,H.Chen, andR. S. Sippel, “What is the optimal treatment for children with primary
hyperparathyroidism?” Journal of Pediatric Surgery, vol. 45, no.6, pp. 1142–1146, 2010.
T. Igarashi, Y. Sekine, H. Kawato, S. Kamoshita, and Y. Saigusa, “Transient neonatal distal renal tubular acidosis with
secondary hyperparathyroidism,” Pediatric Nephrology, vol. 6, no. 3, pp. 267–269, 1992.
E. J. Glass and D. G. Barr, “Transient neonatal hyperparathyroidism secondary to maternal
pseudohypoparathyroidism,”Archives of Disease in Childhood, vol. 56, no. 7, pp. 565–568,1981.
A. Sathasivam, L.Garibaldi, R.Murphy, and J. Ibrahim, “Transient neonatal hyperparathyroidism: a presenting feature
ofmucolipidosis type II,” Journal of Pediatric Endocrinology and Metabolism, vol. 19, no. 6, pp. 859–862, 2006.
M. Minagawa, T. Yasuda, Y. Kobayashi, and H. Niimi, “Transient pseudohypoparathyroidism of the neonate,”
EuropeanJournal of Endocrinology, vol. 133, no. 2, pp. 151–155, 1995.
M. Bai, S. H. Pearce, O. Kifor et al., “In vivo and in vitro characterization of neonatal hyperparathyroidism resulting from a de novo,
heterozygous mutation in the Ca2+-sensing receptor gene: normal maternal calcium homeostasis as a cause of secondary
hyperparathyroidism in familial benign hypocalciuric hypercalcemia,” Journal of Clinical Investigation, vol. 99, no. 1, pp. 88–96, 1997.
J. L. Loughead, Z. Mughal, F. Mimouni, R. C. Tsang, and A. E. Oestreich, “Spectrum and natural history of
congenitalhyperparathyroidism secondary to maternal hypocalcemia,”American Journal of Perinatology, vol. 7, no. 4, pp. 350–355, 1990.
U. E. Pazzaglia, G. Beluffi, E. Bianchi,A. Castello, A. Coci, and A. Marchi, “Study of the bone pathology in early mucolipidosis
II (I-cell disease),” European Journal of Pediatrics, vol. 148, no. 6, pp. 553–557, 1989.
W. D. Fraser, “Hyperparathyroidism,”The Lancet, vol. 374, no. 9684, pp. 145–158, 2009.
E. M. Brown, “Clinical lessons from the calcium-sensing receptor,” Nature Clinical Practice Endocrinology andMetabolism,
vol. 3, no. 2, pp. 122–133, 2007.
S. J. Silverberg, P. Gao, I. Brown,P. Logerfo,T. L.Cantor, and J P. Bilezikian, “Clinical utility of an immunoradiometric assay
for parathyroid hormone (1–84) in primary hyperparathyroidism,”Journal of Clinical Endocrinology and Metabolism, vol. 88, no.
10, pp. 4725– 4730, 2003.
M. L. Melamed, J. A. Eustace, L. C. Plantinga et al.,“Third-generation parathyroid hormone assays and all-causemortality in
incident dialysis patients: the CHOICE study,”Nephrology Dialysis Transplantation, vol. 23, no. 5, pp. 1650–1658, 2008.
N. Ljungdahl, M. Haarhaus, C. Linder, and P. Magnusson,“Comparison of 3 third-generation assays for bio-intact parathyroid
hormone,” Clinical Chemistry, vol. 52, no. 5, pp 903–904, 2006.
J. J. Kazama, S. Yamamoto, S. Kameda et al., “Direct comparison between two 1–84PTH assays in dialysis patients,” Nephron
Clinical Practice, vol. 99, no. 1, pp. c8–c12, 2005.
E. A. Felger and E. Kandil, “Primary hyperparathyroidism,”Otolaryngologic Clinics of North America, vol. 43, no. 2, pp. 417–432, 2010.
S. J. Marx, “Hyperparathyroid and hypoparathyroid disorders,” New England Journal of Medicine, vol. 343, no. 25, pp. 1863–
1875, 2000.
E. Shane, “Clinical review 122: parathyroid carcinoma,”Journal of Clinical Endocrinology and Metabolism, vol. 86, no. 2, pp.
485–493, 2001.
A. A. Khan, J. P. Bilezikian, and J. T. J. Potts, “The diagnosis and management of asymptomatic primary
hyperparathyroidism revisited,” Journal of Clinical Endocrinology andMetabolism, vol. 94, no. 2, pp. 333–334, 2009.
J.P.Bilezikian,A. A.Khan, andJ. T. J. Potts, “Guidelines for the management of asymptomatic primary hyperparathyroidism:summary
statement from the third international workshop,” Journal of Clinical Endocrinology and Metabolism, vol. 94, no. 2, pp. 335–339, 2009.
K. J. Snow and A. E. R. Boyd, “Management of individual tumor syndromes: medullary thyroid carcinoma and
hyperparathyroidism,” Endocrinology and Metabolism Clinics of North America, vol. 23, no. 1, pp. 157–166, 1994.
D. S. Levine and S. M. Wiseman, “Fusion imaging for parathyroid localization in primary hyperparathyroidism,”Expert Review
of Anticancer Therapy, vol. 10, no. 3, pp. 353– 363, 2010.
T. W. Swanson, S. K. Chan, S. J. Jones et al., “Determinants of Tc-99m sestamibi SPECT scan sensitivity in
primaryhyperparathyroidism,” American Journal of Surgery, vol. 199, no. 5, pp. 614–620, 2010.
R. D. Gaz, “Revision parathyroid surgery,” Surgery of the Thyroid and Parathyroid Glands, G. W.Randolf,Ed.,
Saunders,Philadelphia, Pa, USA, 2003.
J. L. Cameron, Current Surgical Therapy, Mosby, St. Louis,Mo, USA, 2001.

THORACIC INJURIES
-Dr. Subodh Kumar

Incidence:
Thoracic trauma is one of the causes of a great number of deaths. Deaths due to thoracic trauma mightoccur
before the patients reach the hospital or in the emergency room. Majority of these deaths arepreventable by
correct diagnosis at the right time and appropriate management. Only <10% of blunt injuriesand 15-30% of
penetrating injuries require thoracotomy and the rest of the cases can be managed withsimple procedures.

Pathophysiology:
Thoracic injuries result in hypoxia, hypercarbia and acidosis.
Hypovolemia, perfusion mismatch due to contusion, hematoma etc and changes in intrathoracicpressures
like in tension or open pneumothorax lead to tissue hypoxia. Hypercarbia may result from changes in
intrathoracic pressures and metabolic acidosis is the result of hypoperfusion to the tissues.

48
Initial assessment and management:
Initial assessment and management consist of primary survey, resuscitation of vital function s,
secondary survey and definitve care. Care has to be given to the identification of hypoxia at an e arly
stage so that earlyintervention can be done. Life thr eatening injuries due to chest injuries are treated
with airway control andthe placement of chest tube.

Primary survey:
The conditions which are to be identified during primary survey include:
Airway obstruction
Tension pneumothorax
Open pneumothorax
Flail chest
Massive hemothorax
Cardiac tamponade

Airway with cervical spine protection:

Listen to the air movements at nose, mouth and lung fields.
Inspect the oropharynx for any obstruction
Look for the intercostals and sup raclavicular muscle retractions.
Look for laryngeal injury as they can result in acute airway obstruction and may lead to death.
Carefully observe for injuries to the upper chest, posterior dislocation or frac ture dislocation of
sternoclavicular joints. Signs and symptoms of airway obstruction include strido r, change in voice
quality and evident trauma to th base of the neck with palpable defect.

Management include
Establishment and management of a patent airway, possibly by endotracheal intuba tion.
Clearing the airway of any objects.
- Closed reduction of the injury thr ough extension of the shoulders and manual reduction of the fracture.
Special attention has to be paid to the alignment of the cervical spine and it should immbolized till
injury is ruled out.

Breathing and ventilation:

Expose the chest and neck to as sess breathing.
Inspect and palpate for tracheal deviation.
Assess respiratory rate and look for shallow respirations.
Be vigilant for cyanosis which is a late sign of hypoxia in trauma.
The following conditions which affect breathing and ventilation are to be assessed at this stage.

Tension pneumothorax:

A tension pneumothorax develops when there is a 'oneway valve' airleak from the chest wall or thelung.
Air enters the thoracic cavity, results in co mplete collapse of the lung, mediastinum isdisplace ed to the
other side which results in a decreased venous ret rn and compression of theopposite lung.
Most common cause of tension pneumothorax are
Mechanical ventilation of a patient with visceral pleural injury,
When a parenchymal injury fails to seal in simple pneumothorax,
Occlusive dressing of a traumatic chest wall defect or
When there is a markedly displaced thoracic spine fracture.
Signs and symptoms of tensio n pneumothorax include chest pain, air hunger, respiratorydistress,
tachycardia, hypotension, trach al deviation, unilateral absence of breath sounds,n eck vein distension
and cyanosis. Differentiation fro m cardiac tamponade is done by the identification of hyper resonant
percussion notes and absent bre ath sounds on the affectedside.

Management include
Immediate decompression via n eedle thoracocentesis (done by the insertion of a large caliber
needle into second intercostal space in midclavicular line)
49
 Definitive treatment is the insertion of a chest tube into the fifth intercostal space just anterior to
the midaxillary line.
Open pneumothorax (sucking chest wound):
These are large defects in the chest wall which are open. If the opening is two third the size
oftrachea, air may pass from the wound with each respiratory effort which leads to impairedven
tilation and hypoxia and hypercarbia.
Management includes:
Primary closure of the defect w ith occlusive dressing which is covered on three sides. Covering
on three sides results in a flutter valve effect which aid in the movement of air during expiration.
Placement of a chest tube remo e to the wound.
Surgical closure of the wound is often required.
Flail chest:
A flail chest occurs when a se gment of the chest wall does
not have bony continuity. It results incases of multiple rib
fractures. If there is injury to underlying chest wall or
restricted chest wall movement due to pain, hypoxia may
result. There is paradoxical chest movement and most of
thetimes flail chest may not be apparent due to splinting of
the chest wall. Dia gnosis is done through a chest X ray
which may indicate several rib fractures and
ABG analysis suggesting hypoxia.
Management includes:
Adequate ventilation
Adequate oxygenation with humidified oxygen
Fluid resuscitation
Analgesia to improve ventilation
Definitive management with re-e xpansion of lung.
Massive hemothorax:
Occurs when there is an accumulation of large amount of blood (>1500ml or 1/3rd or more
ofpatient's blood volume) in the chest cavit y. Presentation may be as hypotension or shock. M ost
common cause of hemothorax is penetrating ch est injury. The patient may present with shock,
absent breath sounds and dullness to percussion.
Management includes:
Restoration of blood volume and decompression of chest cavity. Cryst alloids and blood
products are to be used.
Insertion of a chest tube (38 French).
Auto transfusion of the blood ma y be done.
Early thoracotomy may be warranted in cases of massive hemothorax. Thoracotomy may also be
required if there is a continuous blood loss of 200ml/hour for 2 to 4 hours.
Cardiac tamponade:
Most commonly seen in penetrating injuries but may also occur in blunt injuries. He
mopericardium may result in decreased venous return and cardiac output. Removal of a small a
mount of blood via pericardiocentesis may result in immediate improvement of the patient's
condition. Clinically, diagnosis is done by identification of Beck's triad (elevation of venous
pressure, decreased arterial pressure and muffled heart tones). Pulsus p radoxus and
Kussmaul's sign may or may not b e present.Pulseless electric activity (PEA) in the a bsence of
tension pneumothorax and hypovolemi a suggests cardiac tamponade. Diagnostic measures
include Focused assessment sonography in trauma (FAST) and echocardiogram.
Management includes:
Subxiphoid pericardiocentesis
Definitive management is thoracotomy and pericardiotomy with evacuation of blo od andrepair of
the injured heart and associated stru ctures.
Subxiphoid pericardial window o r emergency thoracotomy and pericardiotomy may be
performed in the ER.
Resuscitative thoracotomy ma y be done in patients who reach the ER puulseless, but have
myocardial electrical activity. Re moval of blood, repair of the injuries and open ca rdiac massage
may be done. Cross clamping of the descending aorta slows blood loss and ensures adequate
supply to brain and heart.
Secondary Survey:
The conditions to be identified during se condary survey are
Simple pneumothorax.

50
Hemothorax.
Pulmonary contusion.
Tracheobronchial disruption.
Blunt cardiac injury.
Traumatic aortic disruption.
Traumatic diaphragmatic injury.
Meditational traversing wounds.

Simple pneumothorax:
It results from air entering the potential space between the visceral and parietal pleura. It may be
caused by penetrating or blunt trauma, lung laceration, and thoracic spine fractures. Signs and
symptoms include decreased breath sounds and hyper resonance on percussion.
Management includes:
Chest tube insertion
Special attention has to be paid that general anesthesia or positive pressure ventilationshould
never be administered in a patient who sustains traumatic pneumothorax who is atrisk for
unexpected intraoperative pneumothorax until a chest tube is inserted..

Hemothorax:
A hemothorax is caused by lung laceration or laceration of an intercostal vessel orinternal
mammary artery resulting from either penetrating or blunt chest injury.
Thoracic spine fractures also may result in
hemothorax. Management include:
Chest tube insertion.
Operative intervention should be considered if significant blood loss is present(>1500ml or
200ml/hour for 2to4 hours).

Pulmonary contusion:
This is the most common lethal chest injury. Careful observation of the patients withsuspected pulmonary
contusion should be done as the respiratory failure in these cases maydevelop only slowly. Management:
If there is significant hypoxia (PaO2</=65mmHg or SaO2 </=90% on room air), intubation and
ventilation should be done during the first hour after injury.
Monitoring with pulse oximetry, ABG, ECG should be done.

Tracheobronchial tree injury:

Injury to the trachea or main bronchus and might be commonly overlooked during theprimary survey. Most of
the injuries occur within an inch of the carina and there is a highmortality rate before and after reaching the ER
associated with these injuries. Signs andsymptoms include hemoptysis, subcutaneous emphysema or tension
pneumothorax with a mediastinal shift. If there is persistent air leak after chest tube insertion in
pneumothorax, there should be suspicion of tracheobronchial tree injury. Confirmation of clinical diagnosisis
done with bronchoscopy. Bronchial intubation of the opposite bronchus may be necessaryto ensure
oxygenation. Immediate surgical intervention might be necessary in cases whereintubation is difficult due to
paratracheal hematoma, associated oropharyngeal injuries or tracheobronchial injury itself.

Blunt cardiac injury:

Blunt cardiac injury often results in myocardial contusion, cardiac rupture or valvular disruption.
Patients with cardiac chamber rupture present with cardiac tamponade and should be diagnosed
during primary survey. If there is atrial rupture, cardiac tamponade will develop only slowly.
Patients often complain of chest discomfort and may have hypotensionand diagnosis is confirmed
by ECG. Patients with myocardial contusion need continuousmonitoring for the first 24 hours,
because of increased risk of sudden dysrythmias.

Traumatic aortic disruption:

This is the most common cause of sudden death after a traumatic injury due to fall or roadtraffic
injuries. Early management can result in survival of the patients if early identificationof the injury
is done. In patients who reach the ER, there is evidence of a contained mediastinal hematoma
which is life saving. Usually there are no typical signs and symptoms.There should be suspicion of
aortic rupture in patients with a history of decelerating force.History should be correlated with
radiological findings. Arteriography and CECT of chest are also helpful. The radiologic signs which
may be present in vascular injury to the chest includes:
- Widened mediastinum
-Obliteration of aortic knob
-Deviation of trachea to the right
-Obliteration of space between pulmonary artery and
aorta -Depression of left main stem bronchus
51
 -Deviation of esophagus to right
-Presence of pleural or apical cap
-Left hemothorax
-Fractures of first or second rib or scapula
Management include: primary repair of aorta or resection of the injured area and grafting.

Traumatic diaphragmatic injury:

This injury is most commonly diagnosed on the left side, as the liver protects it on the right side of
the diaphragm. In blunt trauma, large tears lead to herniation and in penetrating trauma there
aresmall perforations which lead to herniations, which might even take years to manifest. There
arechances of missing these injuries as they are often misinterpreted as elevated diaphragm, acute
gastric dilatation, loculated pneumohemothorax or sub pulmonary hematoma. Suspicion
isconfirmed by the presence of gastric tube on chest X ray and also presence of peritoneal lavage
fluidin chest drainage tube. VATS, laparocoscopy and MRI might be helpful in diagnosis.
Management is surgical repair of the injury.

Mediastinal traversing wounds:

These injuries are caused by penetrating objects which traverse the mediastinum and injures
the heart, great vessels, tracheobronchial tree or esophagus. Diagnosis is made by the
identification of an entrance wound in one hemithorax and the exit wound in the other. There
are chances that a missile is lodged in the other hemithorax.Management includes:
-Bilateral chest tube insertion
-Monitoring of blood loss
-Indications for thoracotomy are same as those of massive hemothorax.

OTHER MANIFESTATIONS OF CHEST INJURIES:

Subcutaneous emphysema.
Crushing injury to the chest (traumatic asphyxia).
Rib, sternum and scapular #.
Blunt esophageal rupture.

Subcutaneous emphysema:
Often results from airway and lung injury. Most of the time, do not require treatment.
Crushing injury to the chest:
These injuries may lead to compromise in ventilator function and result in hypoxia and hypercarbia.
This may sometimes produce traumatic asphyxia which is sudden extreme increase in venous
pressure in superior venacava along with hypoxia. Associated injuries should be treated.
Rib, sternum and scapular #.
Most common sign indicating a fracture is pain on movement resulting in splinting of the thorax and
thereby impairing ventilation, oxygenation and cough. Eventually this may result in atelectasis and
pneumonia. Fracture of the scapula, first or second ribs or sternum suggests increased level of
injury and careful attention has to be given for assessment ofhead, neck, spinal cord, lungs and
great vessels. Fracture of lower ribs should increase suspicion for hepatosplenic injury. Immediate
reduction of sternoclavicular fracture is indicated as dislocation might cause superior venacaval
obstruction. Operative interventions in sternal or scapular fractures are sometimes required as they
may cause blunt cardiac injury. Adequate analgesia is imperative to ensure adequateventilation and
intercostal block, epidural analgesia and systemic analgesics may be used.
Blunt esophageal rupture:
Most esophageal ruptures are caused by penetrating trauma, blunt esophageal trauma is rare. Blunt
esophageal trauma can be caused by forceful expulsion of the gastric contents into the esophagus
due to a powerful blow to the upper abdomen. A linear tear might beformed on the lower part of the
esophagus which results in leakage of the contents into the mediastinum. Esophageal rupture might
also result from the insertion of NG tube, endoscope or dilators also. Diagnosis is done by contrast
studies and esophagoscopy. Management includes wide drainage of pleural space and definitive
surgical repair of the injury via thoracotomy.

Thoracic injury is common in multiply injured patient and can be associated with life
threatening problems.
• The conditions may be temporarily relieved by simple measures such as intubation, ventilation, tube
thoracostomy, fluid resuscitation & needle pericardiocentesis.
The ability to recognize these injuries & the skill to perform the necessary procedures can be life
saving.
For further reading:
Advanced Trauma Life Support student course manual, 8th edition by American College of surgeons Committee on Trauma. 2008;
ISBN 978- 1- 880696- 31- 6.

52
 PREMALIGNANT CONDITIONS OF CARCINOMA COLON

-Dr. Deepak Ghuliani, Dr. Gaurav Tulsyan

Colorectal cancer (CRC) is a tumour that develops from the progression of acquired or hereditary premalignant
lesions. It arises from interactions among different risk factors (environmental, dietary, familial and hereditary)
that become relevant during the different stages of colorectal carcinogenesis. Colorectal cancers that develop in
individuals without hereditary predisposition are referred to as “sporadic,” and account for 75% of all colorectal
cancers. A potential genetic influence is identified in the remaining 25% of patients, including family history/
familial colon cancer (15% to 20%); Hereditary { Lynch syndrome (5%), and FAP (<1%)}
While colorectal adenoma is the most frequent precancerous lesion, other potentially premalignant
conditions, include chronic inflammatory bowel diseases and hereditary syndromes, such as familial
adenomatous polyposis, Peutz-Jeghers syndrome and juvenile polyposis. Thus identification of these
conditions at an early time provides the opportunity to either prevent the progression to cancer or
diagnosis of cancer at an early curable stage.

GENETIC PATHWAYS TO COLORECTAL CANCER:-

There are at least two well-described genetic pathways leading to the development of colorectal
adenocarcinoma.
The chromosomal instability (CIN) / Loss of heterozygosity (LOH) pathway is the result of an
accumulation of inactivated tumour suppressor genes and overactive proto oncogenes. Tumours
developing along this pathway are characterized by mutations of the APC, p53, and K-ras genes, allelic
loss of 18q, and aneuploidy. The APC gene plays a pivotal role in tumourigenesis. 100% of familial
adenomatous polyposis (FAP) patients, who carry this mutation, develop colorectal cancer if
prophylactic surgery is not performed. Up to 80% of tumors develop along the CIN pathway.

The microsatellite instability (MIN) / Replication error (RER) pathway is the other well-described genetic
cascade implicated in the development of colorectal cancer. These tumours have aberrant DNA
mismatch repair, a near-diploid karyotype, and lower levels of p53, SMAD4, and K-ras mutations but
higher frequencies of BAX, TGF-BIIR, and BRAF mutations. As errors accumulate in microsatellites,
malfunction of genes that contain or are near affected micro-satellites may occur. Interestingly, these
tumours generally arise proximal to the splenic flexure, and carry a better prognosis than those
developing along the CIN pathway. Patients with Lynch syndrome develop malignancy along the MIN
pathway, with mutation in DNA mismatch repair genes. This pathway is also referred to as the
replication error (RER) pathway, and is responsible for around 20% of carcinomas.

53
Some tumors do not fall into any of these defined categories, indicating that other genetic pathways exist.

RISK STRATIFICATION
Patients are stratified into 3 groups depending on their risk of getting CRC. CRC risk assessment in
persons without a known family history is advisable by age 40 years to determine the appropriate age
for initiating screening.
A. Average risk:- Individuals at average risk of developing CRC are those age 50 years or older with a
negative family history and no history of adenoma, sessile serrated polyps (SSPs) (described below
under Screening of Individuals at Average Risk), CRC, or inflammatory bowel disease.
B. Increased risk:- Individuals with a personal history of adenomatous polyps or SSPs, CRC, or inflammatory
bowel disease (IBD) (ie, ulcerative colitis, Crohn’s disease), and those with a positive family history of CRC or
advanced adenomatous polyps are considered to be at increased risk for developing CRC.
C. High Risk:- Individuals with a family history of Lynch syndrome (also known as HNPCC) or with a
personal or family history of polyposis syndromes are considered to be in the high-risk category.

PREMALIGNANT CONDITIONS
INFLAMMATORY BOWEL DISEASES
In Patients with inflammatory bowel disease (IBD) the risk is proportional to the extent and duration of
disease. In ulcerative colitis, the risk of cancer appears to begin after 8 to 10 years of disease and
increases at a rate of about 0.5% to 1.0% per year. Institutional and population-based studies report
the absolute risk to be 2% to 5% at 10 years, 8% to 10% at 20 years, and 20%to 30% at 30 years.

54
The risk is highest in patients with pancolitis (disease extending proximal to the splenic flexure), disease
diagnosed at a younger age, and colitis associated sclerosing cholangitis. Cancer that occurs in patients with
ulcerative colitis can arise in any portion of the large bowel, usually presents in the fourth decade of life, and
appears to carry the same prognosis as colon cancer in general. However, in these patients the disease often
presents at a late stage because endoscopic identification of a malignancy in the setting of active colitis is quite
difficult. Because all currently available screening tests (including repetitive biopsies linking dysplasia and bowel
mucosa transformation to cancer) are problematic, most patients with long-standing colitis will probably benefit at
some point from prophylactic proctocolectomy. The risk of colorectal cancer is also increased in longstanding
Crohn’s colitis, a fact that was underappreciated until recently. Currently it is believed that the cancer risk is
equivalent in Crohn’s and ulcerative colitis patients who have disease of similar duration and extent.

SCREENING IN INFLAMMATORY BOWEL DISEASE:

POLYPS:
Most, if not all, carcinomas develop from a precursor polyp (usually an adenoma), a situation known as the
adenoma-carcinoma sequence. The word polyp is derived from Latin and Greek words meaning “many feet”
and is defined as a mass that protrudes into the lumen of the bowel. It is believed that most polyps originate
as sessile lesions, defined grossly by a broad base without a stalk. Traction can lead to a pedunculated
polyp with a stalk. Several histologic types of colorectal polyps have been described and can be broadly
classified into neoplastic and nonneoplastic based on their malignant potential.
Neoplastic:
adenoma (tubular, villous, tubulovillous)
Serrated ( traditional, mixed, sessile)
Rare (carcinoid, melanoma, lymphoma, mesenchymal)
Non-neoplastic:
Hyperplastic
Inflammatory (pseudopolyps)
Hamartomas (Peutz Jegher, Juvenile Polyposis)
Submucosal lesion (lipoma, neuroma, leiomyoma)
The most common neoplastic polyp is the adenoma, which harbours malignant potential. Serrated polyps
are another type of polyp that also have malignant potential. The most common non neoplastic polyp of the
colo-rectum is the hyperplastic polyp. The National Polyp Study, a multicentre study has given valuable
information regarding the natural history and characteristics of polyps: 66.5% of polyps were adenomas,
11.2% were hyperplastic, and 22.3% were classified as ‘‘other’’ (normal mucosa, inflammatory and juvenile
polyps, lymphoid hamartomas, submucosal lipomas, carcinoids, and leiomyomas).

ADENOMAS:
Adenomatous polyps (adenomas) are benign neoplasms of the epithelium. The distribution of adenomas in
the colon is as follows: ceacum, 5%; ascending colon, 7%;hepatic flexure, 4%; transverse colon, 16%;
splenic flexure, 6%; descending colon, 19%; sigmoid colon, 40%;and rectum, 3%. Adenomas are the most
common type of colorectal polyps and are found in 23% to 58% of adults, and their incidence increases with
age. Adenomas are considered premalignant lesions that can grow in size, become increasingly dysplastic,
and eventually develop into carcinoma. Adenomas may occur sporadically or as part of one of the
hereditary syndromes. Carcinomas are found in 0% to 4% adenomas. The extent of villous component, size
and the increasing age are independent risk factors for high-grade dysplasia. The increased frequency of
high-grade dysplasia in adenomas located distal to the splenic flexure is attributable mainly to increased
size and villous component rather than to location per se.
55
Multiplicity of adenomas affects the risk of high-grade dysplasia but is dependent on size and villous
component and thus is not an independent factor. Invasive carcinomas are uncommon in adenomas
<1 cm, and the incidence increases with and increased size of the adenomas.

Classification:-
Morphological
Sessile: Rarely >4cm
Pedunculated: Can cover entire circumference of colon
Flat adenoma: Flat and/or depressed adenomas are a subtype of colonic adenoma with a
propensity for high-grade dysplasia in10–41% of affected patients regardless of the small size of
these lesions. These lesions, which are flat or slightly raised to less than 2 mm and commonly less
than 1 cm in size, may be overlooked easily on colonoscopy and turn into a cancer before having
reached a size comparable with classic cancers. Recent screening studies, which took advantage
of chromoendoscopy techniques, have confirmed that flat adenomas represent up to 25–36% of all
polyps found in a random cohort and are present in 8–11%of the population.

Histopathological
Tubular (85 – 91%):<20% villous component
Tubulovillous (1%): 20 to 80% villous component
Villous (5-10%): >80% villous component, More common in sessile large distal adenomas.
Polyp Transformation: By definition, the neoplastic nature of an adenomatous polyp represents
dysplasia. It is divided into 3 categories .Low grade dysplasia, intermediate-grade dysplasia, and high-
grade dysplasia (by some also referred to as in situ [Tis] adenocarcinoma).

Adenomas with invasive carcinoma: The term ‘‘invasive carcinoma’’ is applied only when the malignant
cells have invaded the polyp, either sessile or pedunculated, partially or totally, through the muscularis
mucosa into the submucosa. Carcinoma superficial to the muscularis mucosa does not metastasize and
should be classified as atypia (rather than carcinoma in situ or superficial carcinoma). A polyp with invasive
carcinoma or a malignant polyp is an early carcinoma. For the TNM classification, it is a T1NxMx.
In 1985, Haggitt et al. proposed a classification for polyps with adenocarcinoma according to the
depth of invasion as follows:
Level 0—Carcinoma in situ or intramucosal carcinoma.These are not invasive.
Level 1— Carcinoma invading through the muscularis mucosae into the submucosa but limited to
the head of the polyp (i.e.,above the junction between the adenoma and its stalk).
Level 2—Carcinoma invading the level of the neck of the adenoma (junction between adenoma and
its stalk). Level 3—Carcinoma invading any part of the stalk.
Level 4—Carcinoma invading into the submucosa of the bowel wall, below the stalk of polyp but above the
muscularis propria. By definition, therefore, all sessile polyps with invasive carcinoma are in level 4.
Kudo and associates, who for prognostic purposes suggested dividing the submucosal invasion of
sessile malignant lesions into three levels:-
SM1: invasion of upper 1/3rd of submucosa
SM2: invasion of middle 1/3rd of submucosa
SM3: invasion of lower 1/3rd of submucosa.

Haggitt’s pedunculated levels 1, 2, 3, are all in Sm1;pedunculated level 4 can be Sm1, Sm2, or Sm3.

Presentation:
Most adenomatous polyps are asymptomatic and are discovered during screening or surveillance. Bleeding
per rectum is the most common finding if the polyp is situated in the rectum or sigmoid colon. A large
pedunculated polyp in the lower part of the rectum may prolapse through the anus. A large villous adenoma
may manifest as watery diarrhoea; in rare instances it causes fluid and electrolyte imbalance. Intermittent
abdominal pain from recurrent intussusception or spasm may occur with a large colonic polyp but is
unusual. Mild anaemia may follow chronic bleeding from an ulcerative polyp.

Management:
Benign Polyps:
Endoscopic
polypectomy. Follow up:
Low risk polyps (Tubular adenoma or serrated sessile polyp/SSP without dysplasia and =<2 polyps
and <1cm): Repeat colonoscopy at 5-10 yrs , then every 10 yrs.
High risk polyps (villous or tubulovillous, or adenoma or any SSP >1cm or SSP with dysplasia): repeat
colonoscopy at 3 yrs, then every 5yrs.
Incomplete or piecemeal or polypectomy of large sessile polyp: Repeat colonoscopy within 2 to 6 months.
>10 Adenomatous polyps: Consider a polyposis syndrome.
56
 Adenoma with invasive component:
Management is based mainly on the level of invasion and the completeness of the polypectomy. Haggitt’s
levels 1, 2, and 3 can be adequately treated with polypectomy (2-mm margin), whereas polyps with
invasion into Haggitt’s level 4 should be treated like a sessile lesion. Management of sessile lesions is
more controversial. If a sessile lesion cannot be snared in one intact piece with a microscopically clear
margin of at least 2 mm, or if it demonstrates lymphovascular invasion or deep invasion into level Sm3
(lower third of submucosa) the patient should undergo a formal oncologic resection of the colon. The
approach for an adequately removed lesion with a lesser extent of invasion into the submucosa—Sm1
(invasion only into upper third of submucosa), Sm2 (invasion only into upper two-thirds of submucosa)—
should be individualized based on the risk of a surgery versus the risk of lymph node metastases. It is
advisable in any case to tattoo the area of a suspect polyp endoscopically with India ink for later
identification of the site. Follow up: Repeat colonoscopy at 1yr then 3yr then every 5yr.
SERRATED POLYPS:
This is the term coined by Longacre and Fenoglio Preiser in 1990 to describe a new entity of mixed hyperplastic
polyp/adenomatous polyp. Grossly the lesion is flat and smooth; it may look like a plaque or thickened mucosa on
colonoscopic examination. This type of lesion can be easily missed on colonoscopy if the colon is over distended
stretching it flat or under-distended causing wrinkle on mucosa to mask it .Unlike the classic hyperplastic polyps
that are small and restricted to the rectum and recto sigmoid colon, serrated adenomas are larger and occur in
both proximal and distal colon and rectum. Some of the individuals previously reported as having multiple
hyperplastic polyps could instead have had multiple serrated adenomatous polyps.

Classification:
a. Traditional serrated polyps:- can contain low- and high-grade dysplasia of the crypt surface epithelium
b. Mixed polyps:- contain a combination of serrated architecture seen in hyperplastic polyps but with
dysplasia characteristic of adenomas
c. Sessile serrated polyps/ adenomas:- Sessile serrated adenomas are characterized by morphology of
both hyperplastic polyps and traditional serrated polyps. They grow larger than other serrated
adenomas and display changes in the proliferative zone and dilation of crypts at the base, often with
lateral extension parallel to muscularis mucosae, or herniation through it.
Serrated polyps may represent the neoplastic risk of serrated polyposis syndrome (SPS) when they
appear as part of this syndrome. Management: Serrated adenomas are neoplastic polyps. The
treatment is the same as in adenomatous polyps.
HYPERPLASTIC POLYPS:
Hyperplastic polyps are small, sessile mucosal outgrowths that display exaggerated crypt architecture. They arise
from faulty epithelial maturation and a failure of apoptosis. Hyperplastic polyps, also known as metaplastic
polyps, are non-neoplastic polyps commonly found in the rectum as small, pale, and glassy mucosal nodules.
Most are 3 to5mm located predominately in the left colon, although larger ones can be seen in the more proximal
part of the colon. Hyperplastic polyps are generally considered to be non-malignant, though adenomatous
changes can occur. The ability of hyperplastic polyps to develop defective mismatch repair genes and foci of
microsatellite unstable cancers has been documented, strengthening this concept. Additional research has
illuminated an epigenetic pathway, whereby a promoter region in the DNA of hyperplastic polyps is methylated,
resulting in progression along a sequence of steps that leads to a serrated adenoma and eventually carcinoma.
The clinical significance of hyperplastic polyps and serrated adenomas is a topic of emerging importance in the
field of colorectal cancer prevention. When hyperplastic polyps occur as part of a polyposis syndrome, they are
associated with an increased risk of malignancy. The endoscopic and radiologic appearance of the mucosal
abnormalities in hyperplastic polyposis closely resembles FAP, but the syndrome is not believed to be heritable
and does not have any extraintestinal manifestations.
The World Health Organization (WHO) criteria for this entity as follows:
ᜀ Ā ᜀ Ā ᜀ Ā ᜀ Ā ᜀ Ā
t least five histologically diagnosed hyperplastic polyps of which two are greater than 20 mm or
any number of hyperplastic polyps occurring proximal to the sigmoid colon in someone who has
a first-degree relative with hyperplastic polyposis, or
ᜀ Ā ᜀ Ā ᜀ Ā ᜀ Ā ᜀ Ā ᜀ
ore than 30 hyperplastic polyps of any size that are distributed throughout the colon and rectum.
The risk of colorectal cancer being present or developing subsequently in a patient meeting these
criteria are high in case series, but population-based studies have not yet been performed.
Management: While prophylactic colectomy has been proposed for patients with hyperplastic
polyposis, there are no consensus opinions at this time regarding the appropriateness of this
approach .At a minimum, a program of intensive colonic surveillance is indicated.
INFLAMMATORY POLYPS:
Inflammatory polyps, also known as pseudopolyps, arise from mucosal ulceration and repair. They
occur most frequently in the setting of chronic ulcerative colitis but are also seen in Crohn disease
and other forms of colitis. Inflammatory polyps are uniform in width from the base to the head and
consist of islands of inflamed regenerating mucosa surrounded by ulceration. Because of their
aetiology, they nearly always occur in multiples.

57
Patients with inflammatory polyps usually require no treatment other than for the underlying colitis, but the
possibility of neoplastic disease should be excluded .Even though the underlying chronic IBD represents a
high risk for colorectal cancer, the inflammatory polyps as such do not carry a malignant potential. Biopsies
in IBD should therefore also include the more flat-appearing areas rather than the polyps only.

HAMARTOMATOUS POLYPS:-
Hamartomatous polyps are localized overgrowths of normal, mature intestinal epithelial cells. On
endoscopic evaluation, they appear round, pink, smooth, and pedunculated. They are usually lined
with normal epithelium over a submucosal core that does not involve the muscularis mucosae. The
pathogenesis is thought to be mucosal ulceration or inflammation that blocks colonic glands. This
leads to proliferation and dilation of the glands, followed by the growth of granulation and connective
tissue in the area. Histologic evaluation reveals cystic dilation of mucus-filled glands, prominent
fibrous stroma, and rich vascularity. They are also referred to as retention or juvenile polyps.
It appears that sporadic hamartomatous polyps do not have any malignant potential unless they contain
adenomatous components. Symptoms from hamartomatous polyps may include abdominal pain, bleeding
from ulceration diarrhea, intussusception, or transanal prolapse if the polyp isolated in the rectum.
Hamartomatous polyps may occur sporadically (Juvenile polyps), but when more than three are
present, a polyposis syndrome should be considered. Several clinical syndromes manifest with a
polyposis of hamartomatous polyps (Juvenile polyposis, Cowden syndrome, Bannayan-Riley-
Ruvalcaba syndrome, Cronkite-Canada syndrome). These symdromes show an increased likelihood of
developing intestinal cancer due to immature glandular elements in the hamartomatous polyp.
GASTROINTESTINAL POLYPOSIS SYNDROMES
Gastrointestinal polyposis syndromes include a variety of entities that are characterized by the
number and histologic type of colorectal polyps, as well as polyposis of the upper gastrointestinal
tract and specific extraintestinal manifestations.
FAMILIAL ADENOMATOUS POLYPOSIS (FAP):
Familial adenomatous polyposis (FAP) is an autosomal dominant inherited syndrome with near-
complete penetrance. The offspring of affected individuals thus have a 50% risk of inheriting FAP.
However, up to 20% of patients with FAP are new mutations without a family history. This condition is
attributed to a truncating mutation in the germline adenomatous polyposis coli (APC) gene on
chromosome 5q21. Mutations in the APC gene are the first step in the classic pathway for the
development of colorectal cancer, or the adenoma-to-carcinoma sequence.
Germline mutations in one copy of the APC gene leave all cells open to a loss of heterozygosity if their second
copy of APC is mutated or lost. When sporadic mutations of both copies of APC occur in a single cell, this is the
first step in the sporadic adenoma-to carcinoma sequence, and leads to the formation of adenomas. Patients with
FAP already have one mutated copy of the APC gene in each of their cells, so this process is accelerated. The
median age for adenoma development in patients with FAP is 17 years. Untreated patients develop colorectal
cancer at a median age of 40,and death occurs by age 44. Carcinoma arising in the antrum and duodenum after
colectomy is the main cause of cancer related deaths in FAP patients.

Clinical manifestations:
Many patients with FAP present without symptoms, either because of a known family history leading
to screening or during investigation of an unrelated complaint. Some patients are referred for testing
based on extracolonic manifestations.
Intestinal:
Symptoms usually do not develop until there is a full blown development of polyposis. Bleeding from the rectum
and diarrhea are the most common symptoms. A clinical diagnosis of FAP is made when at least 100 colonic
adenomas are identified. Although the rectum is almost invariably involved with polyps, the number of polyps in
each segment of the colon and rectum varies from person to person. In general, the left colon has a higher
density of polyps than the right colon. The diagnosis is made by endoscopic examination of the colon and
rectum or by barium enema studies. It must be confirmed by histologic findings of adenomatous polyps. The
clinical diagnosis is confirmed with APC mutation testing. Typically, DNA from peripheral blood leukocytes of a
clinically affected patient is sequenced. If a pathologic mutation is found, genetic testing is said to be
informative in the family. Thereafter, unaffected family members can be screened
to look for the same mutation.
b. Extra-colonic manifestations:
Endodermal abnormalities: nonneoplastic, as is the case for most gastric polyps, or neoplastic, which is
typical of duodenal, small bowel polyp or periampullary polyps, hepatoblastoma, papillary carcinoma
thyroid. Gastricpolyps are also called fundic gland polyps, and are benign hyperplastic-type polyps.
However, they may be associated with an increased risk for adenomas. Duodenal adenomas are found in
more than 90% of patients with FAP. They can be staged according to the Spigelman staging system,
which takes into account the number and size of polyps, histologic type, and dysplasia. Adenomas in the
duodenum are thought to progress in a similar manner to colorectal polyps. Duodenal cancer risk in FAP
patients is approximately 4%. It is the second most common malignancy in FAP patients after CRC.
58
 Mesodermal abnormalities: Desmoid tumours, osteomas, dental abnormalities, fibromas, lipomas.

Ectodermal abnormalities: congenital hypertrophy of retinal pigment epithelium (CHRPE), brain

neoplasms (80% are medulloblastoma), epidermoid cyst.

Variants of FAP:
Attenuated FAP: Attenuated FAP (AFAP) is a subset of FAP characterized by fewer (<100), more
proximal colonic distribution and later onset of polyps and cancer compared to classic FAP. In one
study, the mean number of adenomas was 25 and the average age of colorectal cancer diagnosis
was 55 years. The average lifetime risk of colorectal cancer is 69%. Extra colonic manifestations are
same as FAP. Cancer risk in upper GI track and thyroid is similar to FAP. Incidence of other
extracolonic manifestations like CHRPE and desmoids are less.
Gardener’s syndrome: osteomas, desmoid tumors, thyroid neoplasms, and congenital hypertrophy
of the retinal pigment epithelium.
Turcot’s syndrome: Polyposis plus brain tumor.

Management:

59
60
61
 LYNCH SYNDROME & FAMILIAL COLORECTAL CANCER TYPE X:
Lynch syndrome is an autosomal dominant familial CRC syndrome characterized by familial predisposition of
early age-of-onset CRC (average age, 44 years), associated with variety of other cancers. It is the most common
familial colorectal cancer predisposing syndrome and accounts for 2% to 3% of all colorectal cancers. There are
two patterns of disease presentation, termed Lynch syndrome I (CRC only) and Lynch syndrome II (CRC and
associated malignancies). Because of the difficulty in differentiating between these two patterns of disease, the
term hereditary non polyposis colorectal cancer (HNPCC) was given to this syndrome. Amsterdam
criteria is used to diagnose Lynch syndrome. Currently, individuals who meet the Amsterdam II Criteria
and have positive gene mutation testing are referred to as having the Lynch syndrome; those who meet the
criteria and are gene mutation test negative are referred to as familial colorectal cancer type X.

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Genetics
Genetically Lynch syndrome is associated with a germline mutation in mismatch repair genes.(MMR). The
first two MMR genes to be identified were MSH2 and MLH1. Each of these proteins forms a heterodimer with
so-called minor partners, MSH6 and PMS2. Microsatellite instability (MSI) refers to changes in small, DNA
sequences. These changes accumulate from the failure of mismatch repair near the coding regions of
growth regulatory genes. In colorectal cancer, these include the tumour suppressor genes transforming
growth factor-β receptor II and BAX, as well as other regulators of the cell cycle, apoptosis, and immune
surveillance. The protein products of these genes then become non functional.
Deficient MMR proteins can also be present in sporadic colorectal cancer cases. However, the
defective function is a result of methylation that silences the gene, rather than a mutation in the gene.
This is called the CpG island methylator phenotype (CIMP). MLH1 is the gene most likely to be affected
in this way in sporadic cases of MSI-H colon cancer.
Microsatellite instability is of prognostic significance in colon cancer. Tumours can be characterized
as microsatellite stable (MSS), as having low microsatellite instability(MSI-L), or as having high
microsatellite instability(MSI-H). Patients with MSI-H colorectal cancer have a better prognosis when
compared to patients with microsatellite-stable tumours of similar stages. The absence of MMR
proteins may also predict decreased responsiveness to 5-fluorouracil–based chemotherapy.
Extracolonic manifestations: Endometrial cancer, ovarian cancer, upper urinary tract urothelial
cancer, gastric cancer, small bowel, pancreatic cancer, CNS cancer, breast cancer.

Diagnosis:
The Amsterdam II Criteria suggest the presence of Lynch syndrome.
At least three relatives who have an HNPCC –associated cancer (colorectal, endometrial, ureter,
renal pelvis, small bowel)
One is the first degree relative of other
two At least two generations are affected
At least one relative is diagnosed at a age<50 years of
age FAP has been excluded.
Another set of guidelines for selecting patients for testing for MSI is the Bethesda Guidelines:

The phenotype in Lynch syndrome includes tumours that tend to be right sided, an increased
incidence of synchronous and metachronous cancers, and tumours that occur at an earlier age
compared to sporadic cancers; 60% of carriers will develop colorectal cancer before age 50.
Patients suspected to have Lynch syndrome based on above criteria are tested further for confirming Lynch
syndrome by testing for MSI or IHC for missing proteins. Those showing positive findings are further subjected to
genetic tests to determine the mutated gene. If the involved gene is known from another affected family member,
or based on loss of a specific MMR protein detected on IHC, only that gene needs to be sequenced.
The phenotype in Lynch syndrome includes tumours that tend to be right sided, an increased
incidence of synchronous and metachronous cancers, and tumours that occur at an earlier age
compared to sporadic cancers; 60% of carriers will develop colorectal cancer before age 50.
Patients suspected to have Lynch syndrome based on above criteria are tested further for confirming Lynch
syndrome by testing for MSI or IHC for missing proteins. Those showing positive findings are further subjected to
genetic tests to determine the mutated gene. If the involved gene is known from another affected family member,
or based on loss of a specific MMR protein detected on IHC, only that gene needs to be sequenced.

Screening:
If Lynch syndrome is confirmed, colonoscopy is advised to start between the ages of 20 to 25 or 2 to 5
years younger than the youngest diagnosis age in the family, whichever comes first, and should be
repeated every 1 to 2 years.

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Treatment:
There can be are four groups of Lynch syndrome patients:
a. Patients who are at risk but do not have cancer or adenomas at the time of presentation:
prophylactic surgery is usually not indicated. In post menopausal women prophylactic bilateral
salphingo-oophorectomy with hysterectomy may be done.
b. Those with newly diagnosed adenomas: Usually managed endoscopically.
c. Those with newly diagnosed cancer: Treatment is as per colon cancer treatment.
d. Those who have undergone segmental colectomy for colorectal cancer in the past.
JUVENILE POLYPOSIS SYNDROME(JPS):
In the solitary form, polyps occur at age 4 to 5 years, whereas in JPS, most polyps present later, with
an average age of 18.5 years at diagnosis.
The diagnosis of JPS is based on meeting one of three criteria: 3 to 10 hamartomatous polyps
detected on colonoscopy; hamartomatous polyps detected outside the colon; or any number of
hamartomatous polyps in a patient with a family history of juvenile polyps.
There are three subtypes of JPS: juvenile polyposis coli, in which hamartomatous polyps are only in
the colon; generalized juvenile polyposis, in which hamartomatous polyps can be found in the colon,
stomach, and small bowel; and juvenile polyposis of infancy, which is characterized by diarrhea,
protein-losing enteropathy, bleeding, and rectal prolapsed. It is often fatal.
Presenting symptoms include rectal bleeding, anemia, abdominal pain, diarrhea, intussusception,
obstruction, and polyp prolapse. Heart defects, polydactyly, clubbing, intestinal malrotation, macrocephaly,
hypertelorism, cleft lip, cleft palate, double renal pelvis and ureter, bifid uterus and vagina, undescended
testes, and supernumerary teeth have all been described in JPS patients. These extraintestinal
manifestations have been reported in approximately11% to 20% of cases.Twenty-five to 50% of JPS patients
have a positive family history. The disease has an autosomal dominant inheritance with variable
penetrance. The genes associated with JPS, SMAD4, BMPR1A, and ENG, are part of the TGF-β family of
proteins.Though sporadic hamartomatous polyps do not confer a cancer risk, individuals with JPS are at
risk of developing adenomatous changes and then carcinoma in their polyps. The estimated risk of
colorectal cancer is between 17% and 48%, occurring at a mean age of 34 to43 years. There is also an
increased risk of intestinal, pancreatic, and gastric cancer in this syndrome.

Surveillance:

Treatment:
Endoscopic. Indications for surgery in JPS are a large number of polyps that cannot be managed
endoscopically, adenomatous change in one or more polyps, and severe symptoms including
diarrhea, hypoproteinemia, and bleeding leading to anemia. Surgical options depend on distribution
and number of polyps.
PEUTZ-JEGHER’S SYNDROME:
PJS is a rare syndrome characterized by gastrointestinal tract hamartomatous polyps (usually <100) and
mucocutaneous melanin pigmentation. The incidence is 1 in 150,000 to 1 in 200,000. PJS is caused by a
mutation in the tumoUr suppressor STK11 gene, known as LKB1, located on chromosome 19p13.3.Twenty-
five percent of PJS patients represent a de novo STK11 mutation, with no family history.

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The most common site is the jejunum and the rest of the small bowel (60%), whereas colonic polyps are
found in approximately half of all cases.112 Gastric polyps are also frequent. Additionally, polyps outside
the gastrointestinal tract including the nose, bronchi, renal pelvis, and biliary tree have all been described.
The characteristic hypermelanotic macules of PJS are most frequently found in the perioral region,
buccal mucosa, digits of the hands and feet, and perianal and genital regions. The most common sites
are the vermilion border of the lips, which is noted in 95% of cases, followed by the buccal mucosa.
Mucocutaneous pigmentation usually appears in infancy. Macules vary in size. Pigmented spots tend
to occur in the first few years of life, reach a maximal level in adolescence, and can fade after puberty.
The most common presentation of PJS is abdominal pain due to intussusception. Patients may also
present with symptoms of obstruction from large polyps, anemia, hematochezia, or hematemesis.
Patients with PJS have an estimated risk of cancer ranging between 23% and 93%. The average age of first
detected malignancy is 43 years. The syndrome has been linked to adenocarcinoma of the esophagus,
stomach, small intestine, and colon. Extraintestinal cancers of the thyroid, breast, lung, pancreas,
gallbladder and biliary tree have all been described. In women, there is an increased risk of malignancies of
the ovary and uterus and in men there is an increased risk of Sertoli cell tumour of the testis. The major
cause of death in PJS patients is malignancy. Dysplasia and neoplasia in PJS polyps is extremely rare.

Treatment:
Surgical intervention in patients with PJS is indicated for symptomatic lesions, complications related to polyposis,
polyps larger than1.5 cm that are not able to be removed endoscopically, or cancer. Aggressive endoscopic
polypectomy may limit the need for operative intervention or increase the interval between surgical interventions,
but it is not clear if polypectomy alters cancer risk. The introduction of laparoscope-assisted endoscopic polyp
clearance in PJS may further reduce morbidity and improve management of these patients. Indications for bowel
resection include the detection of adenomatous changes in an incompletely removed polyp, as well as patients
presenting with intussusception, obstruction, or gastrointestinal bleeding. Prophylactic colectomy is not
recommended because of the relatively low incidence of CRC.

WHEN TO SUSPECT POLYPOSIS SYNDROMES:

> 10 adenomas
>2 hamartomatous polyps
>5 serrated polyps
Fulfilling Bethesda or Amsterdam II criteria
Family history

INVESTIGATIONS AND STAGING FOR

COLO-RECTAL CANCER (CRC)
-Dr. Ashish Jakhetiya
INTRODUCTION
Colorectal cancer (CRC) is a common and lethal disease. According to GLOBOCAN 2012 data colorectal cancer is
the third most common cancer in men (746,000, 10% of total) and the second in women (614,000 cases, 9.2% of the
total) worldwide. There is wide geographical variation in the incidence worldwide and patterns vary similarly in
both men and women. However mortality remains lower (694,000 deaths, 8.5% of the total) in CRC. CRC is
diagnosed after the onset of symptoms, or through screening colonoscopy or fecal occult blood testing (FOBT) in
the majority of patients. Standard clinicopathological staging is the best indicator of prognosis for patients with
colo-rectal cancer. In rectal cancer it is very common to use clinical staging for the decision to initiate neoadjuvant
Chemoradiation therapy. Therefore, the accuracy of initial staging is critically important, both for management and
prognosis. Although many other factors have been identified that have an impact on recurrence and survival, none
exceeds stage in terms of prognostic significance.
Historically, a number of different diagnostic interventions have been used to detect colorectal cancer,
often guided by local expertise and preference. The aim of this brief review is to consider indications
and limitations of various modalities including physical examination, biomarkers, colonoscopy,
barium enema, computed tomography (CT), magnetic resonance imaging (MRI), endorectal ultrasound
and positron emission tomography (PET) for staging of colo-rectal cancer. However the optimum
diagnostic strategy for colorectal cancer has not yet been defined.
Staging investigations for colon cancer
The standard initial investigations for colon cancer entails a detail history, physical examination,
complete blood cell count, liver and renal function studies as well as CEA evaluation. Optical
colonoscopy still remains the gold standard however role of CT colonography, barium enema and
flexible sigmoidoscopy is discussed briefly in this section.
Tumor markers — All tumor markers, including CEA, have a low diagnostic ability to detect primary
CRC due to significant overlap with benign disease and low sensitivity for early-stage disease.

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A meta-analysis concluded that the pooled sensitivity of CEA for diagnosis of CRC was only 46 percent. No
other conventional tumor marker had a higher diagnostic sensitivity, including carbohydrate antigen 19-9
(CA 19-9, pooled sensitivity 30%). Furthermore, specificity of CEA is also limited. In the above mentioned
meta-analysis, the specificity of CEA for diagnosis of CRC was 89 percent. Non-cancer-related causes of an
elevated CEA include gastritis, peptic ulcer disease, diverticulitis, liver disease, chronic obstructive
pulmonary disease, diabetes, and any acute or chronic inflammatory state. In addition, CEA levels are
significantly higher in cigarette smokers than in non-smokers.
An expert panel on tumor markers in breast and colorectal cancer convened by the American Society of
Clinical Oncology (ASCO) recommended that neither serum CEA nor any other marker, including CA 19-9,
should be used as a screening or diagnostic test for CRC. However, CEA levels do have value in the follow-
up of patients with diagnosed CRC. ASCO guidelines recommend that serum CEA levels be obtained
preoperatively in most patients with demonstrated CRC to aid in surgical treatment planning, post treatment
follow-up, and in the assessment of prognosis. Serum levels of CEA have prognostic utility in patients with
newly-diagnosed CRC. Patients with preoperative serum CEA >5 ng/mL have a worse prognosis, stage for
stage, than those with lower levels. Elevated preoperative CEA levels that do not normalize following
surgical resection imply the presence of persistent disease and the need for further evaluation.

Colonoscopy — Colonoscopy is the most accurate and versatile diagnostic test for CRC, since it can
localize and biopsy lesions throughout the large bowel, detect synchronous neoplasms, and remove
polyps. Synchronous CRCs, defined as two or more distinct primary tumors diagnosed within six
months of an initial CRC, separated by normal bowel, and not due to direct extension or metastasis,
occur in 3 to 5 percent of patients. When viewed through the endoscope, the vast majority of colon
and rectal cancers are endo-luminal masses that arise from the mucosa and protrude into the lumen.
The masses may be exophytic or polypoid. Bleeding (oozing or frank bleeding) may be seen with
lesions that are friable, necrotic, or ulcerated. Circumferential or near-circumferential involvement of
the bowel wall correlates with the so-called "apple-core" description seen on radiologic imaging.
A minority of neoplastic lesions in the gastrointestinal tract are non-polypoid and relatively flat or depressed.For
endoscopically visible lesions, methods for tissue sampling include biopsies, brushings, and polypectomy. For
lesions that are completely removed endoscopically (with polypectomy, endoscopic mucosal resection, or
endoscopic submucosal dissection), tattooing is important for subsequent localization if an invasive neoplasm is
found, and additional local therapy is needed. Tattoos are typically placed adjacent to or a few centimetres distal
to the lesion, with the location being documented in the colonoscopy report. Among asymptomatic patients,
colonoscopic miss rates for CRCs in the hands of experienced operators range from 2 to 6 percent, and missed
cancers are most frequently on the right side of the colon.
If a malignant obstruction precludes a full colonoscopy preoperatively, the entire residual colon should be
examined soon after resection. In the absence of an obstruction, where colonoscopy is incomplete,
additional options include CT colonography or Pill Cam colon 2, a wireless colon video endoscopy capsule
approved for CRC screening, although its use in patients with symptoms suggestive of CRC (e.g., anaemia,
rectal bleeding, weight loss) is controversial.Colonoscopy is contraindicated in the following situations:
When the risks of the colonoscopy outweigh the expected benefits, consent cannot be obtained for a non-
urgent procedure; a perforation is known or suspected, documented acute diverticulitis, fulminant colitis.
Complications of colonoscopy: Serious complications of colonoscopy are rare (approximately 3 per
1000 screening colonoscopies) and include complications of sedation, complications related to the
preparation, bleeding, and perforation. In a review of 12 studies with 57,742 screening colonoscopies,
serious harm occurred in 2.8 per 1000 examinations. Over 85 percent of the complications occurred in
the setting of polypectomy. Older adults are at increased risk for serious complications compared
with younger patients. Perforation rates vary with the procedure being performed, with rates of 0.01 to
0.1 percent for screening colonoscopy.

Flexible sigmoidoscopy — Over the last 50 years, a gradual shift toward right-sided or proximal colon
cancers has been observed internationally, with the greatest increase in incidence is in caecal primaries.
Because of this, and because of the high frequency of synchronous CRCs, flexible sigmoidoscopy is
generally not considered to be an adequate diagnostic study for a patient suspected of having a CRC.
Nevertheless, screening for CRC using a flexible sigmoidoscope is one of the few modalities that have been
proven through randomized controlled trials to reduce CRC mortality and incidence.

Barium enema — Barium enema is widely available and may be used to investigate patients with
symptoms suggesting of CRC. However, the diagnostic yield of both double-contrast barium enema
(DCBE) alone and the combination of DCBE plus flexible sigmoidoscopy is less than that of
colonoscopy or CT colonography for the evaluation of lower tract symptoms. The yield of DCBE alone
was addressed in a randomized trial comparing DCBE versus CT colonography in 3838 patients with
symptoms suggestive of CRC. Of the 2527 patients assigned to DCBE, the detection rate for CRC or
large polyps was significantly lower (5.6 versus 7.3 percent with CT colonography).

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Computed tomographic (CT) colonography (also virtual colonoscopy)- CTC provides a computer-simulated
endoluminal perspective of the air-filled distended colon. The technique uses conventional spiral or helical
CT scan images acquired as an uninterrupted volume of data and employs sophisticated post-processing
software to generate images that allow the operator to evaluate a cleansed colon in any chosen direction.
Following placement of a thin and flexible rectal catheter, the colon is distended with air or carbon dioxide
throughout its length. Distension is also facilitated by use of smooth muscle relaxants, such as glucagon or
hyoscine, which reduce peristalsis. An uninterrupted volume of data is then acquired through the abdomen
in several seconds during a single breath-hold. Once image data are acquired, they are then used to render
multiplanar reformatted images, mucosal relief profiles, or hybrid surface-shaded or volume-rendered
endoluminal perspectives. CT colonography is an option for colorectal cancer (CRC) screening in
asymptomatic average-risk individuals over the age of 50 years. Other indications for CT colonography
include the evaluation of the proximal colon in patients with an obstructing CRC or evaluation of signs or
symptoms of CRC in whom a colonoscopy cannot be performed due to intolerance, technical difficulty, or in
whom a colonoscopy is contraindicated.
Relative contraindications to CT colonography include the following: Active colonic inflammation (eg, acute
diarrhoea, active inflammatory bowel disease), symptomatic colon-containing abdominal wall hernia, recent
acute diverticulitis, recent colorectal surgery, recent deep endoscopic biopsy/polypectomy/mucosectomy,
known or suspected colonic perforation, symptomatic or high-grade small bowel obstruction.
There is little evidence to inform a safe interval between colonoscopy with
deepbiopsy/polypectomy/mucosectomy or acute diverticulitis and CT colonography. In order to
minimize the risk of perforation, we avoid CT colonography for at least 15 days after a deep biopsy
and six weeks after an episode of acute diverticulitis. The length of the interval between colorectal
surgery and CT colonography should be based on the underlying disease and the location of the
colonic anastomosis, and should be at least six weeks.
Non-completion rates for diagnostic colonoscopy in symptomatic patients are approximately 11 to 12
percent. Reasons for incompleteness include the inability of the colonoscope to reach the tumor or to
visualize the mucosa proximal to the tumor for technical reasons (e.g., partially or completely obstructing
cancer, tortuous colon, poor preparation) and patient intolerance of the examination. In this setting, CT
colonography is highly sensitive for the detection of CRC and can provide a radiographic diagnosis,
although it can over call stool as masses in poorly distended or poorly prepared colons; it also lacks the
capability for biopsy or removal of polyps. CT colonography should be restricted to patients who are able to
pass flatus and capable of tolerating the oral preparation. For clinically obstructed patients, a
gastrointestinal (GI) protocol abdominal CT scan is a good alternative to CT colonography.

CTC versus optical colonoscopy

The available data suggest that CT colonography provides a similarly sensitive, less invasive alternative to
colonoscopy in patients presenting with symptoms suggestive of CRC. However, given that colonoscopy
permits removal/biopsy of the lesion and any synchronous cancers or polyps that are seen during the same
procedure, in our view, colonoscopy remains the gold standard for investigation of symptoms suggestive of
CRC. CT colonography is preferred over barium enema where access to colonoscopy is limited.

PILLCAM 2 — A colon capsule for CRC screening has been approved by the European Medicines Agency
(EMA) in Europe and by the US Food and Drug Administration. In the United States, it is approved for use in
patients who have had an incomplete colonoscopy. While its role in screening for CRC is still uncertain, it
could be considered in a patient with an incomplete colonoscopy who lacks obstruction.

STAGING — Once the diagnosis of colorectal cancer (CRC) is established, the local and distant extent
of disease is determined to provide a framework for discussing therapy and prognosis. A review of the
biopsy specimen is important prior to making a decision about the need for clinical staging studies
and surgical resection

Clinical staging evaluation — Preoperative clinical staging is best accomplished by physical examination
(with particular attention to ascites, hepatomegaly, and lymphadenopathy, and potential fixation of rectal
cancers), computed tomography (CT) scan of the abdomen and pelvis, and chest imaging. Although
frequently obtained preoperatively, liver enzymes may be normal in the setting of small hepatic metastases
and are not a reliable marker for exclusion of liver involvement. The single most common liver test
abnormality associated with liver metastases is an elevation in the serum alkaline phosphatase level.

CT scan — All patients with stage II, III, or IV CRC should undergo chest, abdomen, and pelvic CT, an
approach endorsed by the National Comprehensive Cancer Network (NCCN). The sensitivity of CT for
detecting distant metastasis is higher (75 to 87 percent) than for detecting nodal involvement (45 to 73
percent) or the depth of transmural invasion (approximately 50 percent).
CT scan is not a reliable diagnostic test for low-volume tumor on peritoneal surfaces. The sensitivity of CT
for detecting peritoneal implants depends on the location and size of the implants. The sensitivity of CT for
nodules <0.5 cm was 11 percent and it was only 37 percent for implants 0.5 to 5 cm.
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Chest — the clinical benefit of routine clinical staging with chest CT is also controversial. At least in
theory, imaging of the chest might be of more value for rectal cancer since venous drainage of the
lower rectum is through the haemorrhoidal veins to the vena cava, bypassing the liver, and lung
metastases might be more common. A systematic review of 12 studies including 5873 patients
showed that 732 (9 percent) had indeterminate pulmonary nodules on preoperative chest CT. Overall,
the risk of malignancy for most patients with indeterminate pulmonary nodules (approximately 1
percent) seems sufficiently low that further preoperative diagnostic workup is unnecessary.

Liver MRI — Contrast-enhanced magnetic resonance imaging (MRI) of the liver can identify more hepatic
lesions than are visualized by CT, and is particularly valuable in patients with background fatty liver
changes. A meta-analysis concluded that MRI is the preferred first-line imaging study for evaluating CRC
liver metastases in patients who have not previously undergone therapy. However, newer-generation CT
scanners and the use of triple-phase imaging during contrast administration has improved sensitivity of CT
for detection of liver metastases. In current practice, liver MRI is generally reserved for patients who have
suspicious but not definitive findings on CT scan, particularly if better definition of hepatic disease burden
is needed in order to make decisions about potential hepatic resection.

PET scans — Positron emission tomography (PET) scans do not appear to add significant information to CT
scans for routine preoperative staging of CRC. PET has a role in localizing site(s) of disease recurrence in
patients who have a rising serum carcinoembryonic antigen (CEA) level and non diagnostic conventional
imaging evaluation following primary treatment. In this setting, PET scanning can potentially localize occult
disease, permitting the selection of patients who may benefit from exploratory laparotomy.

STAGING INVESTIGATIONS FOR RECTAL CANCER

The standard staging procedure for rectal cancer entails a detail history, physical examination,
complete blood cell count, liver and renal function studies as well as CEA evaluation. Rectal cancer
imaging has become more critical in staging since the order and types of treatment are often based
upon pre treatment staging as determined by imaging. However, some modalities may confuse the
decision-making and treatment process if they over stage a significant number of patients.

Digital rectal examination: A careful rectal examination by an expert examiner is an essential part of the pre-
therapy evaluation in determining distance of tumor from anal verge or from dentate line, involvement of
anal sphincter, amount of circumferential involvement, sphincter tone, clinical fixation and has not been
replaced by imaging studies or endoscopy. Rigid rather than flexible sigmoidoscopy can most accurately
determine the distance between the distal tumor margin, the top of the anorectal ring, and the dentate line
as well as the orientation within the rectum (e.g., anterior, posterior, left, and right).

CT scans — computed tomography (CT) scanning is a helpful modality for staging distant metastatic
spread and for identifying tumour-related complications (e.g., perforation, fistula formation) but
provides only limited local tumor (T) stage and nodal (N) staging information.
When examining advanced disease, CT determines T stage with an accuracy of 79 to 94 percent; this falls to 52 to
74 percent for smaller tumors are analyzed. The sensitivity of CT for detecting perirectal nodal involvement
depends on the size criteria used to define a node as potentially malignant. The sensitivity of multi-detector row
CT for mesorectal lymph nodes was only 49 percent, although specificity was 92 percent. While sensitivity for
perirectal nodal disease is less for CT than for transrectal endoscopic ultrasound or MRI, the sensitivity of CT for
detection of malignant lymph nodes is higher for rectal than it is for colon cancers. Any perirectal adenopathy is
presumed to be malignant since benign adenopathy is not seen in this area.

ASSESSING T AND N STAGE, AND THE STATUS OF THE CRM — The two imaging modalities that are
most useful for loco-regional tumour staging are transrectal ultrasound (TRUS) and MRI. Both are
more accurate than axial CT scans for assessing the depth of tumor invasion, nodal (N) staging, and
predicting the circumferential resection margin (CRM). The mesorectal fascia is the potential CRM in
patients undergoing TME. If the mesorectal fascia is involved or if the tumor extends to a point that is
within 1 to 2 mm of the mesorectal fascia (i.e., a "threatened" CRM), there is a clear risk that the CRM
will be involved with upfront surgery. These patients are appropriate candidates for preoperative
chemoradiotherapy in an attempt to downstage the tumor.

TRUS — By transrectal ultrasound (TRUS), localized cancers involving only the mucosa and submucosa can
usually be distinguished from those that penetrate the muscularis propria or extend transmurally into perirectal
fat. Several studies comparing the accuracy of TRUS with CT and MRI suggest that TRUS is superior to both for
primary tumor (T) staging of rectal cancer. The accuracy of TRUS ranges from 80 to 95 percent, compared to 75 to
85 percent for MRI, 65 to 75 percent for CT, and 62 percent for DRE. In one systematic review, the accuracy of
TRUS was greatest (95 percent) in distinguishing whether a tumor was confined to the rectal wall or

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invaded through it (ie, T1/2 versus T3 or greater). This is an important distinction as patients with T3 or
T4 rectal cancer are typically offered neoadjuvant chemoradiotherapy rather than upfront surgery.
Despite these data, there is considerable inter-observer variability and a significant learning curve
associated with performing TRUS. TRUS more frequently under stages than over stages the primary
tumour. In comparative studies, the accuracy of TRUS for defining the status of the regional lymph nodes
(approximately 70 to 75 percent) is similar to that of CT (55 to 65 percent) and MRI (60 to 65 percent). The
contribution of TRUS-guided fine needle aspiration biopsy (FNA) to N staging accuracy is controversial.
In patients with anterior tumors, TRUS can assess the extent of tumor involvement of the mesorectal
fascia (the lateral margin), which predicts the distance of the tumor to the circumferential resection
plane after rectal cancer surgery. However, for posterior or postero-lateral tumors, the distance to the
CRM cannot be estimated using TRUS, because neighbouring structures that allow assessment of the
CRM are lacking. In such cases, the distance to the CRM is best estimated using MRI.

MRI — The use of phased-array coil MRI and the development of T2-weighted fast spin sequences
have enabled thin-section (high-resolution) MRI, which is better able to differentiate malignant tissue
from the muscularis propria and define tumor infiltration of the mesorectal fascia. MRI staging of
rectal cancer can be performed using an endorectal surface coil. Now with the advent of gradient coil
systems and high-resolution surface coils, the use of endorectal coils is declining.
In general, MRI tends to have a higher sensitivity than EUS for the assessment of perirectal nodal
involvement because MRI can identify involved nodes on the basis of characteristics other than size.
The utility of preoperative high-resolution MRI in identifying those patients with >5 mm of extramural
tumor invasion was shown in an analysis from the prospective MERCURY trial. "Good prognosis" MRI
characteristics included an MRI-predicted safe CRM and MRI-predicted T2, T3a, or T3b disease with <5
mm spread from the muscularis propria, regardless of MRI-predicted N stage.

TRUS versus MRI — In general, transrectal ultrasound (TRUS) and magnetic resonance imaging (MRI) with
or without an endorectal coil can both be used for primary tumor staging. MRI offers some advantages over
TRUS: it permits a larger field of view and can visualize more proximal tumors, it tends to be less operator
and technique dependent, it allows the study of stenotic tumors, and as noted above, it can characterize
perirectal lymph nodes on the basis of morphology as well as size. A meta-analysis of 90 articles published
between 1985 and 2002 comparing the staging accuracy of MRI, TRUS, and CT, with histopathologic
findings as the reference standard, came to the following conclusions:
For muscularis propria invasion (T1 versus T2), TRUS and MRI had similar sensitivity; specificity of
TRUS was significantly higher (86 versus 69 percent).
For peri-rectal tissue invasion (T3 disease), the sensitivity of TRUS was significantly higher than
either MRI or CT (90 versus 82 and 79 percent, respectively). The results of a subgroup analysis for
MRI techniques (use of a body coil versus a body coil with an addition coil, unenhanced versus
gadolinium-enhanced MRI, low versus high magnetic field strength) disclosed no significant
differences among these techniques in terms of sensitivity or specificity.
For invasion of adjacent organs (T4 disease) and lymph node involvement, estimates for TRUS, CT,
and MRI were comparable.
Technologic advances have led to considerable improvements in MRI of the abdomen and pelvis. Specifically, the
use of phased array coils and rapid gradient echo techniques have allowed imaging during the dynamic
administration of intravenous (IV) paramagnetic contrast agents, such as gadopentetate dimeglumine. This
improves the characterization of the tumor from the surrounding normal structures and permits identification of
enhancing malignant lymph nodes. As these advances become more widespread and migrate from academic
practices to the community, MRI will likely be seen as advantageous compared with TRUS.
At present, either TRUS or high-resolution MRI are acceptable radiographic methods to determine
preoperative local tumor stage. Local expertise may influence the choice of modality.
If available, optimal thin-section (high-resolution) MRI using a surface pelvic phased-array coil MRI is
generally preferred when patients are being evaluated for neoadjuvant therapy approaches because of
its utility in assessing the CRM.
In practice, the information obtained with TRUS and MRI is often complementary, and at many
institutions, both procedures are done preoperatively, particularly for patients whose tumors extend
beyond the muscularis propria. For early staging of T1 and T2 lesions, TRUS offers excellent
delineation of the relationship between a tumor, the mucosa, the muscularis propria, and tumor
extension beyond the muscularis propria. However, TRUS is clearly limited in terms of tumors that
extend deeply into the pelvic side wall or into additional pelvic structures, or for the detection and
characterization of adenopathy in the internal and external iliac (lateral pelvic nodal) distribution.

The Dukes classification and its modifications

In the 1930, Cuthbert Dukes, a Scottish pathologist developed the classification system for rectal cancer
that bears his name. This system and its several modifications are summarised in Table 1 and at this time
are of historical interest only. After all modifications it is now called as modified Dukes classification.

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 Table 1: Dukes classification and its modifications
Dukes staging
Kirklin Modification
Astler-coller modification
Turnbull modification
A Tumor confined to bowel wall
B Tumor penetrates bowel wall
C Lymph node metastasis
B1 Partial penetration of muscularis propria
B2 Full penetration of muscularis propria
C1 Lymph done involvement but did not penetrates the entire
bowel wall
C2 Lymph node involvement and penetrates the entire bowel wall
D Distant metastasis

Staging 7th AJCC/TNM

The Current AJCC/UICC staging system for CRC is now the only classification system that should be
used. The TNM system classifies CRC on the basis of invasiveness (not size) of the primary tumor (T
stage), the number of loco-regional LNs containing metastatic cancer (N stage), and the presence or
absence of distant metastatic disease (M stage). Detailed staging is summarised in Table 2 and 3.
Table 2: AJCC/UICC 7th classification

Primary Stage category definitions

tumor (T)
stage
Tx Primary tumor cannot be assessed
T0 No evidence of primary tumor
Tis Carcinoma in situ: intraepithelial or invasion of lamina propria*
T1 Tumor invades submucosa
T2 Tumor invades muscularis propria
T3 Tumor invades through the muscularis propria into pericolorectal tissues
T4a Tumor penetrates to the surface of the visceral peritoneum**
T4b Tumor directly invades or is adherent to other organs or structures^,**
Direct invasion in T4 includes invasion of other organs or other segments of the colorectum as a result
of direct extension through the serosa, as confirmed on microscopic examination (for example, invasion
of the sigmoid colon by a carcinoma of the cecum) or, for cancers in a retro-peritoneal or subperitoneal
location, direct invasion of other organs or structures by virtue of extension beyond the muscularis
propria (i.e., respectively, a tumor on the posterior wall of the descending colon invading the left kidney
or lateral abdominal wall; or a mid or distal rectal cancer with invasion of prostate, seminal vesicles,
cervix or vagina).
**Tumor that is adherent to other organs or structures, grossly, is classified cT4b.
However, if no tumor is present in the adhesion, microscopically, the classification should be pT1-4a
depending on the anatomical depth of wall invasion.
The V and L classifications should be used to identify the presence or absence of vascular or lymphatic
invasion whereas the PN site-specific factor should be used for
perineural invasion
Regional lymph node (N)
Nx Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
N1 Metastasis in 1 to 3 regional lymph nodes
N1a Metastasis in 1 regional lymph node
N1b Metastasis in 2-3 regional lymph nodes
N1c Tumor deposit(s) in the subserosa, mesentery, or non-peritonealized pericolic or perirectal tissues
without regional nodal metastasis
N2 Metastasis in 4 or more regional lymph nodes
N2a Metastasis in 4 to 6 regional lymph nodes
N2b Metastasis in 7 or more regional lymph nodes
A satellite peritumoral nodule in the pericolorectal adipose tissue of a primary carcinoma without
histologic evidence of residual lymph node in the nodule may represent discontinuous spread, venous
invasion with extravascular spread (V1/2) or a totally replaced lymph node (N1/2). Replaced nodes
should be counted separately as positive nodes in the N category, whereas discontinuous spread or
venous invasion should be classified and counted in the Site-Specific Factor category Tumor Deposits
(TD).
Distant metastasis (M)
M0 No distant metastasis (no pathologic M0; use clinical M to complete stage group)
M1 Distant metastasis
.
M1a Metastasis confined to one organ or site (e.g., liver, lung, ovary, non-regional node).

M1b Metastases in more than one organ/site or the peritoneum

70
 Table 3: TNM stage grouping
Stage T N M
0 Tis N0 M0
I T1 N0 M0
T2 N0 M0
IIA T3 N0 M0
IIB T4a N0 M0
IIC T4b N0 M0
IIIA T1-T2 N1-N2a M0
IIIB T3-T4a N1 M0
T2-T3 N2a M0
T1-T2 N2b M0
IIIC T4a N2a M0
T3-T4a N2b M0
T4b N1-N2 M0
IVA T any N any M1a
IVB T any N any M1b
Staging 8th AJCC/TNM
The most recent (eighth edition, 2017) revision of the TNM staging classification, implementation
includes following
The M1c stage has been introduced to reflect peritoneal carcinomatosis as a poor prognostic factor
Nodal micro-metastases (tumor clusters >0.2 mm in diameter) are now scored as positive given
the results of a meta-analysis demonstrating a poor prognosis in these patients
In addition, the definition of tumor deposits as they apply to regional nodal status is clarified.
In case of tumor deposit but no identified involved LN than N1c category is used. The number
of tumor deposit is not added to the number of positive regional nodes if one or more nodes
contain cancer. Number of tumor deposit should be recorded on staging form as one to four
individual tumor deposits or five or more tumor deposit.
Factors, which are important to consider when making decisions about treatment but are not
yet incorporated into the formal staging criteria are defined:
Preoperative serum carcino-embryonic antigen (CEA) levels
Tumor regression score, which reflects the pathologic response to preoperative
radiotherapy, chemoradiotherapy, or chemotherapy (table 4) and the status of the
circumferential resection margin for rectal cancers.
Lymphovascular and perineural invasion.
Microsatellite instability, which reflects deficiency of mismatch repair enzymes and is both a
prognostic factor and predictive of a lack of response to fluoropyrimidine therapy.
Mutation status of KRAS, NRAS, and BRAF, because mutations in these genes are associated
with lack of response to agents targeting the epidermal growth factor receptor (EGFR).

Table 4: Modified Ryan scheme for tumor regression score

Description Tumor regression

score
No viable cancer cells (complete response) 0
Single cells or rare small group of cancer cells (near-complete response) 1
Residual cancer with evident tumor regression, but more than single cells or rare small 2
groups of cancer cells (partial response)
Extensive residual cancer with no evident tumor regression (poor or no response) 3
Post-operative surveillance in colo-rectal cancer (CRC)
Follow up after definitive treatment has two main objectives. First, patients with history of CRC are at a
higher risk than the general population for a second primary colon cancer. A colonoscopic screening may
benefit early detection of a second primary cancer or detection of a benign polyp, which can be resected
and potentially prevent development of invasive cancer. Second, surveillance may increase the chance of
identifying local, regional or distant recurrence that is potentially curable by surgery.
The American Society of clinical oncology (ASCO) guidelines are physical examination and serum
CEA monitoring every 3 to 6 months for first 3 years, and every 6 months for 4 and 5 years. CT scan of
chest and abdomen are recommended for once a year for first 3 years. NCCN guidelines differ only
slightly in that they recommend annual CT scan for up to 5 years including CT pelvis. Colonoscopy is
recommended at 1 year after resection (or 3 to 6 months after resection if a complete colonoscopy
was not performed prior to surgery) and then 3 years later, and then every 5 years. CT scan and serum
CEA monitoring should not be continued beyond 5 years. Routine monitoring of complete blood
count, liver function test, chest X ray and fecal blood testing are not recommended now.
An elevated CEA level, if confirmed by retesting warrants further evaluation for metastatic disease. This work up
consists of a colonoscopy and CT scan of the chest, abdomen and pelvis. CEA scintigraphy is now not

71
recommended. If no recurrence is detected watchful waiting and repeat CT scan after 3 months versus a
FDG-PET scan can be considered.

REFERENCES
J. Ferlay, I. Soerjomataram, R. Dikshit, S. Eser, C. Mathers, M. Rebelo, D.M. Parkin, D. Forman, F. Bray (2014). Cancer
incidence and mortality worldwide: sources, methods and major patterns in GLOBOCAN 2012. International Journal of
Cancer doi:10.1002/ijc.29210 PMID:25220842.
Edge SB, ed. AJCC cancer staging manual. Vol. 7. Berlin: springer;2010.
Whitlock EP, Lin JS, Liles E, et al. Scre ening for colorectal cancer: a targeted, updated systematic revie w for the U.S.
Preventive Services Task Force. Ann Intern Med 2008; 149:638.
Chukmaitov A, Bradley CJ, Dahman B, et al. Association of polypectomy techniques, endoscopist volu me, and facility
type with colonoscopy complications. Gastrointest Endosc 2013; 77:436.
Reumkens A, Rondagh EJ, Bakker CM et al. Post-Colonoscopy Complications: A Systematic Review, Time Trends, and
Meta-Analysis of Population-Based Studies. Am J Gastroenterol 2016; 111:1092.
U.S. Preventive Services Task Force. Screening for colorectal cancer: U.S. Preventive Services Task Force
recommendation statement. Ann Intern Med 2008; 149:627.
Zalis ME, Perumpillichira J, Del Frat e C, Hahn PF. CT colonography: digital subtraction bowel cleansing with mucosal
reconstruction initial observations. Radio logy 2003; 226:911.
Passman MA, Pommier RF, Vetto JT. Synchronous colon primaries have the same prognosis as solitary colon cancers.
Dis Colon Rectum 1996; 39:329.
Mulder SA, Kranse R, Damhuis RA, et a l. Prevalence and prognosis of synchronous colorectal cancer: a Dutch
population-based study. Cancer Epidemiol 2011; 35:442.
Pickhardt PJ, Hassan C, Halligan S, M armo R. Colorectal cancer: CT colonography and colonoscopy for detection--
systematic review and meta-analysis. Radiology 20 11; 259:393.
Atkin W, Dadswell E, Wooldrage K, et a l. Computed tomographic colonography versus colonoscopy for investigation of patients
with symptoms suggestive of colorectal cancer (SIGGAR): a multicentre randomised trial. Lancet 2013; 381:1194.
Locker GY, Hamilton S, Harris J, et al. ASCO 2006 update of recommendations for the use of tumor markers in
gastrointestinal cancer. J Clin Oncol 2006; 24:5313.
Liu Z, Zhang Y, Niu Y, et al. A systematic review and meta-analysis of diagnostic and prognostic serum biomarkers of
colorectal cancer. PLoS One 2014; 9:e103910.
Duffy MJ, van Dalen A, Haglund C, et al. Clinical utility of biochemical markers in colorectal cancer: Eur opean Group on
Tumour Markers (EGTM) guidelines. Eur J Cancer 2003; 39:718.
Nordholm-Carstensen A, Wille-Jørgens en PA, Jorgensen LN, Harling H. Indeterminate pulmonary nod ules at colorectal
cancer staging: a systematic review of predictiv e parameters for malignancy. Ann Surg Oncol 2013; 20:4022.
Isbister WH, al-Sanea O. The utility of pr e-operative abdominal computerized tomography scanning in colorectal
surgery. J R Coll Surg Edinb 1996; 41:232.
Taylor AJ, Youker JE. Imaging in colore ctal carcinoma. Semin Oncol 1991; 18:99.
Taylor FG, Quirke P, Heald RJ, et al. Preoperative high-resolution magnetic resonance imaging can identify good
prognosis stage I, II, and III rectal cancer best managed by surgery alone: a prospective, multicenter, European study.
Ann Surg 2011; 253:711.
Bipat S, Glas AS, Slors FJ, et al. Recta cancer: local staging and assessment of lymph node involveme nt with
endoluminal US, CT, and MR imaging--a meta-analysis. R adiology 2004; 232:773.
Al-Sukhni E, Milot L, Fruitman M, et al. Diagnostic accuracy of MRI for assessment of T category, lymph node metastases, and
circumferential resection margin involve ment in patients with rectal cancer: a systematic review and meta-analysis. Ann
Surg Oncol 2012; 19:2212.
Taylor FG, Quirke P, Heald RJ, et al. P reoperative magnetic resonance imaging assessment of circumf erential resection margin
predicts disease-free survival and local recurrence: 5-year follow-up results of the MERCURY study. J Clin Oncol 2014; 32:34.

ADJUVANT AND NEOADJUVANT THERAPY FOR

COLORECTAL CANCER
-Drr. Manoj Andley

The survival following surgical therapy of colorectal cancers can be potentially improved wit h
chemotherapy as well as radiotherapy. Colon cancers with risk factors for local and systemic recurrence
are treated with adjuvant chemotherapy. Rectal cancers with inc reased recurrence risks are typically
treated with neo-adjuvant and adjuvant regimens combining chemothe apy and radiation therapy.
Following are the indications for adjuvant therapy in colon cancer:
Stage III Colon cancer 6 months FOLFOX/CapeOx/FLOX
Stage II Colon cancer with follow ing high risk factors(5-FU/LV)
T4
Occlusion/Perforation
Poorly differentiated tumor(exclu ding high MSI)
Lympho-vascular invasion
<10 examined lymph nodes
Further assessment of risk in colon cancers can be done by
Mismatch repair (MMR) Testing
Multigene assays like Oncotype DX colon cancer assay, ColoPrint,
ColDx Insufficient data to recommend these tests.

Principles of adjuvant therapy

FOLFOX has been found superior to 5-FU therapy only in stage III cancers
72
 5-FU/leucovorin has been reco mended in high risk stage II colon cancers. Additio n of oxaliplatin
has no survival benefit in this stage.
Table 1: Comparison of FOLFOX 4 with FLOX regimen
Table 2: Comparison of FOLFOX 4 with modified FOLFOX 6 regimen

Radiotherapy for resected colon cancer

Adjuvant radiation concurrently delivered with 5-FU chemotherapy can be used f or selected
patients with T4 tumors penetrating to a fixed structure or recurrent disease. Intra-operative
radiotherapy should also be considered.

Neo/Adjuvant Therapy For Rectal Cance r

Following are the indications of neo-adjuvant therapy in rectal cancers:
T3, T4
Node Positive
Conversion of a distal rectal tumor to one amenable to a sphincter sparing operation. 5-
FU PVI (Protracted Venous Infusion) or Bolus 5-FU is used with concurrent radiotherapy.

Table 3: Comparison of PVI and Bolus 5-FU

Neo-adjuvant therapy for rectal cancer

There is a potential to decrease tumor seeding at the time of surgery.
Some tumors that may require sacrifice of the sphincter may experience a response adequate to
allow a sphincter-preserving approach.
Postoperative radiation may be less effective in the relatively hypoxic postoperativ e pelvis, which
may render malignant cells more re sistant to radiation. Moreover, toxicity may be increased
because the small bowel often falls into the pelvis, which is the area targeted for radiation.

Current Treatment Regimens For Neo-adjuvant/Adjuvant Radiation Or Chemo-radiation For Rectal

Cancer
Preoperative chemo-radiation: 5 040 cGy in 28 fractions of external beam radiotherapy with concurrent
5-FU (bolus or continuous venous infusion) or Capecitabine oral chemotherapy, followed by resection
in approximately 1 month, and consideration of postoperative adjuvant chemotherap y
Preoperative radiation alone: 5 fractions of 5 Gy radiation therapy each
Postoperative chemoradiation: t wo cycles of systemic therapy (5-FU or oxaliplatin based chemotherapy
followed by 5040-5400 cGy in 28-30 fractions of external beam radiotherapy with concurrent 5-FU (bolus or
continuous venous inf usion) or capecitabine oral chemotherapy, followed by consideration of
two further cycles of systemic therapy
Adjuvant chemotherapy for rectal cancer
Use of FOLFOX in rectal cancer has been extrapolated from adjuvant colon cancer t rials.
73
Neo/Adjuvant Therapy for Metastatic Colorectal Cancer
Select patients with liver only or liver dominant metastatic disease have liver directed
treatment options: Hepatic Arterial Infusion of 5-FUDR
TACE
Liver directed radiation
Tumor ablation
FOLFIRI/FOLFOX/CAPE-OX/FOLFOXIRI
ANTI-EGFR INHIBITORS with k-ras mutation testing( Cetuximab, Panitumab)
ANTI-VEGF INHIBITORS (Bevacizumab, Ziv-Aflibercept, Regorafenib)

Role Of Endoscopy In The Management Of Colorectal Cancer

Pedunculated polyps found to contain cancer confined to the submucosa of the polyp or stalk
and with favorable histological features be managed endoscopically.
Colonic SEMS (self-expandable metal stent) may also be used as a “bridge to surgery” for
patients with malignant obstruction who are surgical candidates.
Endoscopic alternatives to surgical decompression include placement of a SEMS, tumor
debulking, and placement of a decompression tube.

SURGICAL OPTIONS FOR COLORECTAL CANCER

- Dr. P K Mishra, Dr. Pravin Kumar

Colorectal cancer (CRC) is the third most commonly diagnosed cancer and 3rd leading cause of cancer
death in males as well as females in U.S. Although burden of disease is higher in the west, the disease is
prevalent worldwide. When diagnosed, 40% patients have localized disease, 37 % regional disease, 20%
distant metastasisand 5 % are unstaged. Survival rate at 5yrs are 90%,68% and 11% and at 10yrs are 85%,
58% and 6.6% respectively for local, regional and distant disease.1 Seventy-five per cent of colorectal
cancers are sporadic and rest are associated with FAP, HNPCC, IBDandpatient with strong family history of
colorectal cancer.Genetics in Colorectal cancers have been extensively studied. Treatment strategies have
evolved over time and role of chemoradiotherapy in adjuvant and neoadjuvant settings is better understood
now. Epidemiology, genetics, diagnosis, staging and chemoradiotherapy may be looked in standard texts
referred. This brief synopsis gives a small over view of the surgical options in colorectal cancer.

Surgical options for colorectal cancer

The primary goal of surgical treatment is to eradicate colonic disease, draining LN and contiguous involved
organs.Stage, synchronous colonic tumor and presence of colorectal cancer syndrome are important factors for
deciding optimal surgical management. General medical condition is also important in determining surgical plan
as most of the pre-operative deaths occur due to cardiac and pulmonary complications. Bowel preparation for
colorectal cancers has been controversial. Broadly, it is not required for right side cancers and has staged a
comeback for left sided cancers especially in laparoscopic settings. Laparoscopic surgery, in well-chosen patients
has been shown to give equivalent results to open surgery while offering faster recovery. For advanced, bulky or
difficult tumours open surgery remains a better option.

Anatomy
Knowledge of arterial, venous and lymphatic anatomy is important for optimal surgical management.
Artery:
Ascending and proximal transverse colon are derived from midgut, having arterial supply from SMA
through ileocolic, right and middle colic artery.Distal transverse, descending and sigmoid colon are
hindgut derivatives having arterial supply from IMA through left colic and sigmoid artery. Collateral
blood supply for colon is through marginal artery of Drummond and arc of Riolon.
Marginal artery of drummond
It is arterial arcade along inner border of colon formed by anastomosisof terminal branches of SMA
and IMA. Arc of Riolon
It is inconstant artery connecting proximal SMA or one of its branch to proximal IMA or one of its
branch. Rectum, hindgut derivative, is supplied bysuperior rectal artery(continuation of IMA) in upper
third. Middle and lower third of rectum is supplied by middle and inferior rectal artery, branch of
internal iliac artery (hypogastric artery).
Veins:
Venous drainage of colon and rectum is same as arterial supply with majority drainage into portal
venous system. This is direct route of metastatic spread to liver. Only variation in venous drainage
from arterial supply is IMV joining splenic vein before draining into portal Venous System.

74
Rectum has direct venous drainage. Upper rectum drains into Portal Venous System. Middle and
inferior rectal vein into IVC, providing a direct route for haematogenous spread outside the abdomen.

Lymphatic drainage:
Lymphatic begins in gut wall as a plexus beneath lamina propria and drain into submucosal andintramuscular
lymphatics. Subserosa drains into epicolic LN, located in colon wall.This nodal group runs along inner bowel
margin between intestinal wall and arterial arcade. Epicolic nodes drain into paracolic nodes which follows route
of marginal arteries. Epicolic and Paracolic LN represent majority of colonic LN and involved in regional
metastatic disease. Paracolic nodes drain to intermediate nodes (along their colonic vessels) which drain into
principal nodes (begins at SMA and IMA) and are contiguous with paraaortic chain.

75
1) Right colon 1. Intermediate nodes Superior mesentric nodes
2. Lymphatic along SMV Periportal LN
Left colonLN along marginal artery left colicintermediatenodes Inferior mesenteric nodes
Rectum
Upper 1/3rd LN along IMV
Lower 2/3rd Int.iliac (hypogastric) LN Paraaortic LN
Lower 1/3rdalso LN along pudendal vessels Inguinal LN

Total MesorectalExcision (TME)

Basic concept is to pursue dissection in the ‘holy plane’ of embryological origin. Rectum is enveloped
by mesorectal fat and lymphovascular structure posteriorly and laterally which limits the lateral
spread of cancer. Rectal dissection entails removal of entire mesorectum for distal and middle rectal
cancers. For upper rectal cancers 5 cm of mesorectum below the tumour needs to be removed. Holy
plane is also avascular. TME is standard of care for rectal cancers.

Pelvic Autonomic Nerves

Superior hypogastric plexus, inferior hypogastric plexus and pelvic plexus form the autonomic network of pelvis.
Injuries to these are responsible for bladder, bowel and sexual dysfunctions. Nerves are to be protected while
ligating the IMA (superior hypogastric nerves), separating from ureter and gonadal vessels (Superior and inferior
hypogastric plexus) and at level of dissection of seminal vesicles (inferior hypogastric nerve).

Surgical options:
Primary tumour and its arterial, venous and lymphatic supply along with mesentery, attached
omentum and contiguous involved organ is removed.
High ligation (flush ligation) of appropriate vessel in colon cancer.

Local excision for rectal cancer

1)Trans-sphincteric
2)Trans-coccygeal
3)Trans anal
4)Transanal endoscopic micro-surgery(TEMS)
Trans anal minimally invasive surgery (TAMIS)

Indication:-
1)Absence of LN enlargement in preoperative imaging
2)Mobile (non fixed)
3)<30% circumference involved (Shackelford -40%)2
< 3cm in size (Shackelford – 4cm)2
Within 8-10 cm of anal verge
6)Adenomas, T1and few favourableT2 lesion
No lymphovascular or perineural invasion
Confirmation of mural sterilization in post neoadjuvant complete response yT0.

Transphincteric:
First described by Mason. It is performed in prone position. Less favoured technique due to post op
incontinence.
Transcoccygeal or posterior proctotomy:
Popularized by Kraske. Used for middle or distal third rectal tumor on the posterior wall. It is done in
prone jack-knife position. After excising skin and subcutaneous tissue, coccyx is excised. Rectum
mobilizedand tumor removed with 1cm margin. Advantage of this procedure is mesorectum and
perirectal nodes adjacent totumour removed en block.
Transanal:
This is most convenient approach for removing distal rectal cancer which lies within 3-5 cm of dentate
line.Complication: fecal impaction, retention of urine, urinary tract infection,delayed hemorrhage.
Transanal endoscopic microsurgery (TEMS):
Devised by Gehard Buess from Germany. It provides accessibility to middle and upper third rectal tumor which
would otherwise require laparotomy,through improved visibility and instrumentation. This can be used for
selected lesion upto 15 cm from anal verge. Caution must be taken for higher lesion because full thickness
excision can result inperforation into abdomen that will result is leakage of gas into the abdominal cavity and
injury to intraperitoneal organ.
Two components:
Operating instruments- operating rectoscope,stereoscope and modified laparoscopic
instrument for cutting andsuturing.
Endo surgical unit-suction irrigationand continuous monitoring of intra rectal pressure.
76
Marginof resectionshould be 10 mm in case of invasive carcinoma3. Complications includ e
haemorrhage and peritoneal breach which would need laparotomy.Most of studies now suggest that
TEM sho uld be reserved for lesion restricted to mucosa and upper 1/3rd of submucosa only.

TAMIS
TAMIS evolved as TEMS despite of some advantages couldn’t become popular. This was because of
complexity and limited maneuverabilit y of the instruments. TAMIS uses SILS or gel port and standard
laparoscopic instruments. Indications ar same as for TEMS.

REFERENCES:
The MD Anderson Surgical Oncology Ha ndbook, 5th edition: 347-410.
Shackelford’s surgery of the alimentary tract, 7th edition, Vol 2:2051-2121.
Textbook of Surgical Gastroenterology: Ed Mishra PK, Vol 2:1128-1140.

COLONOSCOPY
-Dr. Pawan Lal, Dr. Rohit Kaushik

Colonoscopy is a tool for the evaluation of the large intestineto screen for colon cancer, define the risk of
colon cancerrelative to the general population, determine the presenceof disease, and treat speci fic
disorders related to the colon.

Indications
Table 1: Diagnostic and therapeutic indications for colonoscopy.
Diagnostic indications
Evaluation of an abnormality on barium enem a (or virtual colonoscopy) such as a filling defect or strictuure
Evaluation of unexplained gastrointestinal ble eding
Haematochezia in absence of convincing an orectal source
Melena after an upper gastrointestinal source has been excluded
Presence of faecal occult blood
Unexplained iron deficiency anaemia
Surveillance after removal of adenomas
Surveillance after resection of colorectal can cer
After identification of adenomas during sigm oidoscopy or for clearing the colon of synchronous neo
plasia in patients with colorectal cancer
In patients with ulcerative pan colitis or Crohn’s colitis of ≥ 8 years’ duration or left-sided colitis ≥ 15
years’ duration
Colorectal cancer screening Chronic inflammatory bowel disease of the colon, if more precise diagnosis
or determination of the extent of activity of disease will influence management
Clinically significant diarrhoea of unexplained origin
Intraoperative identification of a lesion not apparent at surgery (e.g., polypectomy site, location of a
bleeding site)
Th erapeutic indications
(from the American Socie ty for Gastrointestinal Endoscopy guideline)
Treatment of bleeding from such lesions as vascular malformation, ulceration, neoplasia, and
polypectomy site (e.g., electrocoagulation, heater probe,
laser or injection therapy)
Foreign body removal
Excision of colonic polyp
Decompression of acute nontoxic megacolon or sigmoid volvulus
Balloon dilation of stenotic lesions (e.g., anas tomotic strictures)
Palliative treatment of stenosing or bleeding neoplasms (e.g., laser, electrocoagulation, stenting)
Marking a neoplasm for localization

A second classification of indications is by risk. Not all factors that increase the risk of co lonoscopy are
well defined. However, indications that are as sociated with high risk include:
Decompression of acute colonic pseudo-
obstruction Polypectomy of large polyps
Stricture dilation
Stent placement.

77
Pre-existing conditions associated with high risk include:
Acute colonic pseudo-
obstruction Sigmoid volvulus
Caecal volvulus
Prior radiation therapy
Chronic steroid use
Colonic strictures
Extensive pelvic adhesions
Severe diverticular disease
Severe colitis.
Patients with cardiac or pulmonary disease who are graded 3 or higher on the American
Societyof Anaesthesiologists scale are at risk for cardiopulmonary compromise with sedation.

Screening procedures, which are generally performed in asymptomatic persons who are healthy or
relatively healthy, have thus far been associated with a lower risk of perforation.
Age is a powerful predictor and male gender is a consistent predictor of both adenomas and advanced
adenomas. Recently, it has been recognized that the person who performs the procedure can be more
important than both the patient’s age and the patient’s gender in predicting adenomas at colonoscopy. In
the absence of bleeding (no report of haematochezia, negative stool tests for occult blood, and normal
haemoglobin level), symptoms such as abdominal pain and altered bowel habit have no predictive value for
colorectal cancer. In these persons, the yield of colonoscopy for neoplasia essentially reflects the age,
gender, and family history of the patient. This observation becomes the justification for making a positive
diagnosis of irritable bowel syndrome in many women aged less than 50 years with nonbleeding colonic
symptoms. To summarize, the decision of whether to proceed with a colonoscopy should take into account
at least the anticipated risk and the potential benefit of the procedure. The potential for benefit is often best
estimated by calculating the potential yield for neoplasia, which is again a function of the indication (with
regard to cancer) and the patient’s age, gender, and family history (with regard to adenomas).

Recommendations for colonoscopy screening in the US are summarized in Table 2.

Table 2: Indications for screening colonoscopy.

In average-risk persons: Begin at age 50 years, repeat every 10 years.
In persons with one first-degree relative Begin at age 40 years, repeat every 10 years.
diagnosed with colorectal cancer (or adenomas)
at age > 60 years:
In persons with two first-degree relatives (or Begin at age 40 years or 10 years before age of
adenomas) diagnosed with colorectal cancer (or diagnosis of youngest relative, repeat every 5
adenomas) or one first-degree relative with years.
colorectal cancer or adenoma) at age < 60
years:
In persons with hereditary nonpolyposis Begin at age 20–25 years, repeat every 1–2
colorectal cancer: years until age 40 years, then repeat every year.
In women with endometrial or ovarian cancer Begin at time of diagnosis, repeat every 5 years.
diagnosed at age < 50 years:
In patients with FAP in whom surgery is being Repeat every 6–12 months.
postponed:
In patients with possible or gene test proven Repeat every year until surgery is performed.
attenuated FAP:

Table 3: Contraindications.
Absolute
Competent patient who refuses to consent
Consented patient who is unable to cooperate and cannot be adequately sedated
Known perforated viscus communicating freely with the peritoneal cavity
Toxic megacolon
Fulminant colitis
Relative
Acute diverticulitis (diagnosis established)
Hemodynamic instability
Recent myocardial infarction or pulmonary embolism
Immediate postoperative stage
Very large and/or symptomatic abdominal aortic aneurysm
Pregnancy
78
ANTIBIOTIC PROPHYLAXIS IN COLONOSCOPY:
Table 4: Recommendations for routine antibiotic prophylaxis for colonoscopy (from AHA [1] and ASGE
Condition Recommendations
Any cardiac valve condition Not recommended (AHA)/ Optional for “high risk” (ASGE)
Vascular prosthesis within first year of placement Not recommended (AHA)/ Optional (ASGE)
Prosthetic joints and orthopaedic prosthesis Not recommended (ASGE)
Patient with cirrhosis and GI bleeding Recommended (ASGE)
The immunocompromised patient Not recommended (ASGE)

ANTIPLATELETS PROPHYLAXIS
For NSAIDs/aspirin, the guideline recommends that:
In the absence of a pre-existing bleeding disorder, endoscopic procedures may be performed
on patients taking aspirin andother NSAIDs in standard doses.
Warfarin management depends on both the procedure risk and the patient’s underlying
thromboembolic risk.
The use of LMWH has increased due to its ease of use in clinical practice and secondary to its superior
efficacy in certain clinical situations.
LMWH and newer antiplatelet agents have not been included in endoscopic studies yet although GI
bleeding rates have been described in large prospective cardiac studies. Current ASGE guidelines on
the use of LMWH and antiplatelet agents are based on procedure risk.
Table 5: Management of LMWH in patients undergoing endoscopic procedures.
Procedure risk Recommendation
High Consider discontinuation at least 8 h before procedure
Low No change in therapy
Reinstitution of LMWH should be individualized
Management of antiplatelet medication (clopidogrel or ticlopidine) in patients undergoing
endoscopic procedures
High Consider discontinuation 7–10 days before procedure
Low No change in therapy

Procedure risk
High-risk procedures Low-risk procedures
Polypectomy Diagnostic
Biliary sphincterotomy EGD ± biopsy
Pneumatic or bougie dilation Flexible sigmoidoscopy ± biopsy
PEG placement Colonoscopy ± biopsy
EUS-guided FNA ERCP without endoscopic sphincterotomy
Laser ablation and coagulation Biliary/pancreatic stent without endoscopic sphincterotomy
Treatment of varices EUS without FNA
Enteroscopy
Table 6:Management of anticoagulation and antiplatelet agents in patients undergoingcolonoscopy.
High risk of thromboembolism Low risk of thromboembolism
High procedure risk Discontinue warfarin 3–4 days Discontinue warfarin 3–5 days before procedure
before procedure. Consider heparin before procedure
Reinstitute INR is below therapeutic level Warfarin after procedure
Low procedure risk No change in anticoagulation. Elective No change in anticoagulation. Elective procedures
procedures should bedelayed while INR shouldbe delayed while INR is insupratherapeutic
is insupratherapeutic range range

PREPARATION
A colon preparation regimen should provide safe and rapid cleansing acceptable to patients with
minimal discomfort. The ideal method would:
Reliably empty the colon of faecal material;
have no effect on gross or microscopic appearance of thecolon;
Require a short period for ingestion and evacuation;
Cause no discomfort;
Produce no significant shifts of fluids or electrolytes [2].
The regimen should be simple and appropriate for usein inpatients and outpatients [15].
The presently availablemethods do not meet most of these criteria and few have been carefully
studied. Problems with patient compliance, safety, and adequacy of cleansing have prompted
continued investigation into alternative forms of cleansing.Three popular options for colon
preparation are diet and cathartic regimens, gut lavage, and phosphatepreparations.

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 Table 7:Diet and cathartic regimens
Diet Clear liquids for 72 h, or 1–3 days of a diet designed to result in a minimal colonic
faecal residue
Cathartic Magnesium citrate 240 mL of chilled, X-prep liquid 240 mg (extract of Senna fruit,
Purdue Frederick Co., Norwalk, CT, US)
Additional cathartic Bisacodyl 20 mg orally and/or two bisacodyl suppositories
Enemas Tap water enemas until clear the evening before or morning of the procedure

Gut lavage
Antegrade per oral gut lavage using saline or balanced electrolyte solutions was found to provide rapid and
effective colon cleansing but the 7- to 12-L required volume necessitated nasogastric administration and
was not well tolerated. These saline and electrolyte solutions led to weight gain, sodium retention, and fluid
shifts, prompting studies that incorporated mannitol or polyethylene glycol (PEG) for osmotic balance so
that there is no net loss or change in the body’s electrolyte composition.

Polyethylene glycol electrolyte lavage solution

Polyethylene glycol electrolyte lavage solution (PEG-ELS) hassignificant advantage to saline or electrolyte
solutions when compared for water and electrolyte shifts. Intestinal perfusion of PEG-ELS resulted in mean water
absorption of 64 mL/h, whereas infusion of a basic electrolyte solution without osmotic balance resulted in water
absorption of 799 mL/h. Routine clinical cleansing using 3–4 L over 3–4 h would result in absorption of 190–250
mL of fluid with PEG-ELS and 3400–3200 mL of electrolyte solution without osmotic balance. Since saline lavage
frequently requires 7–12 L over 6–12 h, these patients have the potential for over 8 L of water absorption.Clinical
trials have established the safety of PEG-ELS for colon cleansing preparation for colonoscopy, barium enema X-
ray examination, intravenous pyelograms, and colon surgery. Compared with diet and cathartic methods with
enema administration, PEG-ELS had better patient acceptance. When compared with clear liquid and minimum
residue diet methods, PEG-ELS was superior, with cleansing efficacy rated good or excellent in 92% of PEG-ELS,
69% of clear liquid diet, 80% of 3-day minimum residue diet, and 80% of 1-day minimum residue diet groups (P <
0.001). Interestingly,it was noted that the 72-h clear liquid diet, enemas,and cathartic group had the least optimal
cleansing. No clinically significant hematologic, biochemical, electrolyte, or metabolic abnormalities have been
found with PEG-ELS colon cleansing.

Sulfate-free electrolyte lavage solution

A sulfate-free electrolyte lavage solution (SF-ELS) was developed in an attempt to improve patient compliance by
decreasing the salty taste and “rotten egg” smell noted with PEG-ELS. Whereas the mechanism of action of PEG-
ELS cleansing is affected by the osmotic properties of PEG and by an electrochemical gradient for ion transport
created by sodium sulfate, SF-ELS action is primarily based on the osmotic effects of PEG, as sulfate was
eliminated from the formulation. The PEG polymer isolates water from the solution and when PEG molecular
weight is greater than 1500 (as seen with PEG 3350 in PEG-ELS and SF-ELS), it is poorly absorbed in the
gastrointestinal tract. PEG is inert and not fermented by colonic bacteria to combustible gases. Clinical trials for
colonoscopy, barium enema radiography, and elective colonic surgery have shown SF-ELS to be safe and
effective. Raymond et al. randomly assigned patients to receive PEG-ELS and SF-ELS in random order for the first
2 L of lavage fluid. Subjects were then asked to choose which solution they would prefer to consume for the last 2
L of preparation. More study subjects preferred SF-ELS and more were willing to repeat SF-ELS than the
traditional PEG-ELS if colon cleansing was needed in the future.

Table 8: Reported and potential adverse experiences related to colon preparation.

Gut lavage cleansing
Disagreeable taste
Hypothermia
Volume-related symptoms: fullness, nausea, bloating
Aspiration
Reactivation of bleeding
Esophageal tear
Perforation
Lavage-induced pill malabsorption
Allergic reaction: angioedema, urticaria, or anaphylaxis
Bisacodyl ischemic colitis
Phosphate cleansing
Electrolyte disturbances
Hyperphosphatemia
Hypocalcemia
Vomiting
Dehydration
Colonic aphthous ulcerations
Seizures
Acute phosphate nephropathy
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Phosphates
Phosphate preparations offer another alternative. Oral sodium phosphateis administered as 45 mL of solution
diluted with water to90 mL on the evening before the procedure, and repeated 12 h later or 4 h prior to
colonoscopy. Oral sodium phosphate has been shown to be at least as effective as, or better than, PEGELS. It is
also generally well tolerated. Vanneret al. [84] randomized 102 patients to either oral sodium phosphate or PEG-
ELS. Overall, patients found sodium phosphate much easier to consume, and colonoscopists rated cleansing
achieved with sodium phosphate as better than obtained with PEG-ELS. Hyperphosphatemia was noted, but it was
transient and the preparation was considered safe. Sodium phosphate monobasic, monohydrate, and sodium
phosphate dibasic, anhydrous are used in a tablet formulation. Forty tablets are taken with 10 glasses of water
(about 2.5 L). Rex et al. [90] found that 28 or 32 tablets are effective, and a new smaller tablet containing less
microcrystalline cellulose, thus reducing colonic residue, was approved by the Food and Drug Administration
(FDA) in March 2002. The new formulation is now marketed as Osmoprep.

Safety
Oral sodium phosphate contains 48 g of monobasic sodium phosphate and 18 g of dibasic sodium phosphate per
100 mL, making it very hypertonic. The phosphate salt must be diluted to prevent vomiting, and administration
should be followed by adequate oral fluids.Although some studies have found no significant (or clinically
insignificant) metabolic changes resulting from oral sodium phosphate, these data were limited and adverse
events attributed to phosphate have been recognized. Significant hypocalcaemiaand hyperphosphatemia were
observed. An FDA safety review concurs and raises awareness of increased risk in patients with congestive heart
failure, ascites, renal insufficiency, dehydration, debility, gastrointestinal obstruction, gastric retention, bowel
perforation, colitis, megacolon, ileus, inability to take oral fluid, or patients taking diuretics or medications that
may affect electrolytes, who may experience serious adverse events. Baseline and post-treatment laboratory
evaluations of serum sodium, potassium, chloride, bicarbonate, calcium, phosphate, blood urea nitrogen, and
creatinine be obtained, especially in those at risk who take more than 45 mL of oral sodium phosphate in a 24-h
period. Nephrocalcinosis usually seen from hypercalcemia has been reported in normo-calcemic patients
presenting with acute renal failure after bowel cleansing with sodium phosphate solution or tablets. This “acute
phosphate nephropathy” is accepted as an emerging issue. In contradiction to reassurance that careful hydration
could avoid the complication, Pelham et al. report that hyperphosphatemia after phosphate bowel preparation may
not be overcome even with up to 4.4 L of hydrating fluids. Another FDA report raises concern about phosphate
tablets after seizures were seen to be associated with electrolyte disturbances after Visicol. Phosphate
preparation hasbeen noted to induce recto-sigmoid aphthous ulcerations, and in one study aphthous ulcers
occurred in 5.5% of study subjects receiving sodium phosphate preparation. The FDA has restricted over-the-
counter phosphates for cleansing preparations and the manufacturer removed oral sodium phosphate from the
market.

Sulfates
A new formulation of sulfates has been developed as a laxative and bowel cleansing preparation.
Preliminary data suggest that this low-volume method has significant efficacy without the safety
issues of phosphates. Other options
There are various other ways to prepare for colonoscopy, including intraoperative colonic irrigation
and pulsed irrigation.
Contraindications for colonoscopy preparation
Preparation should not be performed if there is a contraindicationto colonoscopy.

Table 9: Contraindications
Absolute
Competent patient who refuses to consent
Consented patient who is unable to cooperate and cannot be adequately sedated
Known perforated viscus communicating freely with the peritoneal cavity
Toxic megacolon
Fulminant colitis
Relative
Acute diverticulitis (diagnosis established)
Hemodynamic instability
Recent myocardial infarction or pulmonary embolism
Immediate postoperative stage
Very large and/or symptomatic abdominal aortic aneurysm
Pregnancy

Incomplete obstruction or gastroparesis could be tested with a 1-L trial of gut lavage solution with
careful observation. Per oral preparation may not be effective with ileus. Early reports of preparation
comparison studies used a grading scale by colonoscopists unaware of the type of preparation used,
which visually graded the adequacy of preparation as follows:

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 1 (poor)-large amount of faecal residue, unacceptable;
2 (fair)-enough faeces to prevent a completely reliable examination;
3 (good)-small accumulationsnot interfering with a thorough
examination; 4 (excellent)-no more than small bits of adherent faeces.
Grades 2–4 were considered acceptable cleansing for colonoscopy; grades 3 and 4 were optimal.

CAPSULE ENDOSCOPY
Capsule endoscopy is the most recent advance in video capsule technology. Since the technology is
portable, it offers the possibility of an out-of-hospital, or even home-based, examination and with it the
likelihood of significantly improved compliance. Consisting of an ingestible pill-sized video camera similar
to the small bowel capsule, CE has redesigned optics that are specifically configured for surveying the
colonic mucosa: automatic light control; a wider 125° field of view that is captured at two frames per second
by a CMOS (complementary metal–oxide semiconductor) chip at each end of the capsule; and an increased
depth of view to 40 mm to allow for the more distant views of the colon. A pre-programmed “sleep” mode is
incorporated into the design in order to preservebattery life following initial activation during a 2-h period
after first ingestion as the capsule traverses the small bowel, extending the overall battery life to around 10
h. The capsule is larger as a result of these modifications (32 mm by 11 mm), which are made to both
accommodate the revised optics and achieve a specific weight-to-volume ratio that optimizes capsule
progression through the colon. The sensor array, data recorder, and workstation used for reporting
purposes are similar to those required for small bowel capsule endoscopy. The Rapid5 software allows
images captured by each end of the capsule to be viewed individually or simultaneously, but in other
respects is familiar to anyone used to reporting small bowel capsule endoscopy studies.

Submarine” luminal views of the colon obtained at PillCam Pedunculated polyp as seen at colonoscopy (left)
Colon capsule endoscopy demonstrating a normal transverse and PillCam Colon capsule endoscopy (right).
colon (left) and a colorectal cancer (right).

INTESTINAL STOMAS
-Dr. Nikhil Gupta
COLOSTOMY
Definition: It is an artificial opening made between the large bowel and skin, to divert faeces and flatus
to the exterior, where it can be collected in an external appliance. Effluent is usually solid.
Temporary Colostomy:
Indications:
1- Distal Obstruction.
2- Defunction a low rectal anastomosis after anterior resection of the
rectum. 3- Following traumatic injury to the rectum or colon.
4- During operative treatment of a high fistula in
ano. 5- Fulminant Colitis (IBD).
6- Complicated Diverticular disease.

Site of the colon used:

A segment which has a mesentery:
1- Transverse colon. (Disease involve Lt. side of the colon)
2- Sigmoid colon. (|Disease involve the rectum or rectosigmoid junction)

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Types of temporary colostomies:
A- Loop colostomy: bringing a loop of bowel to the surface where it is held in place by a plastic or glass rod
passed through the mesentery. Firm adhesion of the colostomy takes place after 7 days then the bridge can be
removed.
Closure: follows the surgical cure or healing of the distal lesion for which the temporary stoma was constructed (a
distal loopogram) is best performed to check there is no distal obstruction or any problem at the site of previous
surgery). Also the stoma should be mature (at least 2 months after establishment of the colostomy).

Steps of loop colostomy:

GA is important since traction on the mesentery causes pain and nausea. A transverse incision -
10cm long with removal of a disc of skin is made for transverse colon (in the Right upper
abdomen midway between the umbilicus and xiphisternum over the rectus abdominis muscle
and extending laterally to the lateral border of the rectus muscle), while for the sigmoid colon (in
the left iliac fossa with a muscle cutting incision).
Cut down all layers including the rectus muscle which is divided transversely, ligating and
dividing the epigastric artery.
The most proximal loop of colon is prepared by removing the omentum from its anterior
surface (only in Transverse colon), then a small hole is made in the mesocolon through which a
rubber tube is passed to facilitate delivery of the colon through the incision.
The laparotomy wound should be closed at this stage.
The colonic loop is held by an underlying glass rod or by a colostomy bar or skin bridge incised
initially. The colon is then opened on its antimescolic border longitudinally (along the taenia coli).
Sutures are used to fix the colonic serosa to the abdominal wall, and colonic mucosa to the
surrounding skin.
The finished loop colostomy should allow one finger to pass down on each side.

B- Double Barreled colostomy: the colon is divided so that both ends can be brought separately to the
surface with a skin bridge intervening.
Advantage: ensures that the distal segment (colon, rectum) is completely defunctioned (Absolute Rest).

C- Hartmann’s Procedure: This includes a proximal End Colostomy with a distal closed colonic
segment. This procedure can be used when resecting a tumour of the Lt. site of the colon or in
Complicated diverticular disease.
Permanent Colostomy
Indications:
1- Rectal carcinoma excision (A-P resection- End colostomy
2- Inoperable rectal or colonic carcinoma - Loop colostomy

Technique of End colostomy

The best site is through the lateral edge of the rectus sheath 6cm above and medial to the anterior superior
iliac spine. The colon is stitched in place immediately by sutures placed between the colonic margin and the
surrounding skin ,i.e; it is usually sutured flush to the skin. The point at which the colon is brought to the
surface must be carefully selected to allow a colostomy bag to be applied without impinging on a bony
prominence. An important point after the colostomy has been made is to close the lateral space between the
intraperitoneal segment of the colon and the peritoneum of the pelvic wall to prevent internal herniation and
strangulation of the bowel. Sigmoid colostomy is usually brought out at the Lt. iliac fossa. Transverse
colostomy is usually brought out in the Rt. hypochondrium.

Complications of Colostomy construction:

1- Prolapse (it leads to dysfunction, it is not important in temporary colostomy which sooner or later
will be closed, only in permanent cases which will need refashioning or resiting)
2- Retraction (due to tension and infection)
3- Para-colostomy Hernia.( especially in end terminal colostomy). Treatment should include resiting
the colostomy and the hernia defect closed.
4- Bleeding.
5- Necrosis and gangrene of the distal end (due to loss of viability due to interference with its blood
supply, too much ligation of mesenteric vessels).
6- Stenosis of the colostomy orifice (occurs at the mucocutaneous junction, due to infection and cellulitis which is
followed by scarring).Treatment should include refashioning of colostomy site with excision of skin disc.
7- Peri-colostomy abscess and fistula (occurs when a misplaced suture that fixes the colon to the
deeper layers of the abdominal wall instead of passing through the serosa, passes through the whole
thickness of the bowel). The abscess bursts and forms a fistula. Treatment should include laying the
track open and leaving it to granulate.
8- Colostomy diarrhea.

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 ILEOSTOMY:
Definition: It is an artificial opening made between the ileum and skin of the abdo minal wall, to
divert intestinal contents to the exteri r, without a sphincter to control the timing of its emptying.
Effluent is usually liquid.
End Ileostomy.

Indications: In cases where total proctocolectomy is done.

1- Ulcerative colitis.
2- Crohn’s disease.
3- Familial polyposis Coli.
Loop Ileostomy.
Indications:
1- Small bowel perforation (mostl y enteric or tubercular) when either repair not done or repair needs
protection due to lot of contamination, edematous bowel and poor general condition of the patient.
2- as an alternative of a loop colo stomy for defunctioning (after low rectal anastomosis following
anterior rectal resection procedure or ile oanal pouch procedure following total proctocolecto my)

Technique of Ileostomy:
The ileostomy opening should be 5cm l ateral to the umbilicus and brought out through the lateral edges
of the rectus abdominus muscle. It is usually made in the Rt. Iliac fossa. It should be spouted.

Complications of Ileostomy:
1- Prolapse.
2- Retraction.
3- Para-ileostomy hernia.
4- Bleeding.
5- Necrosis and gangrene of the distal e nd.
6- Stenosis of the ileotomy orifice.
7- Skin reaction around the stoma. (Exc riation, erosion, sloughing)
8- Fluid and electrolyte imbalance. (ileostomy flux).

Types of Bowel Stomas

1- End (terminal).
2- Loop.
3- Double Barrel. (Two ends brought to the surface separately with a skin bridge intervening))
4- Paul-Miculikz. (Two ends brought to the surface together where the adjacent serosal surfaces are
hitched by sutures, and adjacent mucosal surfaces are sutured)
5- Separation proximal faecal fistula from a distal mucous fistula.

Criteria taken into consideration whe n positioning a stoma:

1- Away from any bony prominence.(Anterior superior iliac spine , Symphysis pubis)
2- Away from the umbilicus.
3- Away from any previous surgical incision.
4- Visible when the patient stands.
5- Comfortable for the patient

FEED ING JEJUNOSTOMY AND GASTROSTO MY

-Dr. Pawan Lal, Dr. Nisha Gautam

GASTROSTOMY
A gastrostomy is defined as an opening made in the wall of the stomach which communicate s to
the skin through the anterior abdominal wall.

Indications
To feed
Cerebrovascular accident
Tumors of larynx, pharynx, oral cavit y, esophagus
Proximal gastric cancers
To decompress
Duodenal trauma (in association wit h triple ostomies)
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Temporary Gastrostomy
Advantages
More comfortable as compared to nasogastric tube
Does not interfere with respiration or pulmonary toilet as compared to nasogastric tube
Food is broken down better in stomach than in jejunum therefore gastrostomy is preferred than
jejunostomy Disadvantages
Gastrostomy can lead to gastro-esophageal reflux, aspiration and pneumonias (therefore an anti-
reflux procedure should also be done for comatose patients)

Stamm’s Gastrostomy
A point is chosen on the middle of the anterior surface of the stomach where it lies against the
anterior abdominal wall without tension. Tube exits in left hypochondrium. Two concentric purse
string sutures of silk or semi-permanent sutures are taken forming a snug seal and serosal lining for
the tube tract. Tube size – 20 to 26 F Malecots

Witzel Gastrostomy
A tunnel or inverted tract is fashioned along the anterior stomach wall so that tube penetrates the
stomach at a distance from point where it exits the abdominal wall.
Advantages claimed for this procedure is to prevent leakage around the tube. Disadvantages are it is
more liable to leakage than is Stamm’s because the tube tract is longer and requires more suturing
and tube itself is required to be bent acutely in two places.

Permanent Gastrostomy
Indications
Stroke Victims
Patients with birth asphyxia
Patients with severe psychomotor retardation
Patients with head and face trauma
Progressive neurologic disease

Advantages
Nutrition can be provided for long periods
Tube or mechanical device is needed only when food is actually being introduced.
Between feedings the patient needs only to keep the external stoma covered.
1. Depage- Janeways gastrostomy
A flap is formed with its base at greater curvature and converted to tube by two layer closure of the
defect in the stomach.
Beck-Jianu gastrostomy
Long gastric tube is fashioned from greater curvature of the stomach based on let gastro-epiploic artery.

Figure 1: Beck Jianu gastrostomy based on left gastro-epiploic artery

3. Glassman’s Gastrostomy
Mucosa lined gastrostomy in which leakage is prevented by creating two areas of constriction in a
cone shaped diverticulum formed from anterior wall of stomach.

Figure 2: Glassman’s gastrostomy – continent gastrostomy with purse string Lambert’s

sutures. Jejunal interposition
Jejunum segment is interposed between stomach and abdominal wall. Jejunal segment is 30 cm long
85
4. Percutaneous endoscopic gastrostomy

FEEDING JEJUNOSTOMY
Enterotomy is made in the jejunum ~ 25 to 30 cm from the ligament of Treitz.
Indication
To provide temporary and permanent enteral
nutrition Advantages
Preferred approach for enteral nutrition over gastrostomy when prolonged nutritional support
is required. Lower rates of postoperative aspirations as compared to gastrostomy
Stamm’s jejunostomy
A point is chosen, 25- 30 cm from the ligament of treitz. Tube exits in left lumbar. Two concentric purse string
sutures of silk or semi-permanent sutures are taken forming a snug seal and serosal lining for the tube tract.

Witzel jejunostomy
A simple purse-string suture of 000 silk is placed in the desired area. A catheter is then threaded into the lumen at
the desired distance and the purse-string suture is tied. A serosal tunnel of sutures are additionally placed in a
running manner for a distance of 5 to 6 cm and sutured around the proximal tube with another purse-string suture.
The entire loop of intestine is anchored to the parietal peritoneum using several 000 silk.

Laparoscopic jejunostomy

THYROIDECTOMY – SURGICAL TECHHNIQUE

-Dr. Vivek Aggarwal

Introduction
The thyroid gland has been described throughout history but was first so named by the Romans for being a
"shield-shaped" gland. Not only were thyroid masses mentioned in the literature throughout the 12 th and
13th century, but in 1170 Robert Frugardi described the extirpation of a goiter. The procedures were often
fraught with complications, including massive hemorrhage, infection, and injury to surrounding structures,
all of which were associated with morbidity and mortality rates of nearly 40%.
Jules Boeckel of Strasbourg introduced the collar incision to thyroid surgery in 1880, and this approach was
popularized by Theodore Kocher. Theodor Kocher, whose own reported mortality rate for thyroidectomy
dropped to 1%, was awarded the Nobel Prize in 1909 for his advancement of thyroid surgery in the late
19th century.
The surgical technique of thyroidectomy, as well as adjunct technology, continued to advance. Most
recently, various new instruments (ie, harmonic technology) and approaches including video-assisted
thyroidectomy and robot-assisted thyroidectomy have emerged.

Indications
Thyroid nodule
Multinodular goiter
Thyroid malignancy
Thyrotoxic nodular goiter
Medically resistant Graves
disease Thyroid abcess
Diagnostic for undetermined thyroid nodules
86
Important anatomical pictures

Blood supply of thyroid Recurrent laryngeal nerve

Pic-Berry's ligament. Inferior thyroid/recurrent laryngeal nerve

Relationship

External recurrent laryngeal nerve

87
Preoperative workup
For thyroid nodules, the patient should have a thyroid ultrasound, and a fine-needle aspiration should
be performed for large or suspicious nodules. Those with lesions suspicious for papillary or
medullary thyroid cancer should also have an ultrasound performed of the lateral neck compartments
to be evaluated for metastatic disease.
CT imaging of the neck is helpful, especially in patients with significant goiters, to rule out substernal
extension. Note that contrast-enhanced scans can limit the ability to provide radioactive iodine in
patients with iodine-avid tumors.
Additionally, all patients undergoing thyroidectomy should have their vocal cord function evaluated
and documented prior to surgery.

Equipments
A basic head and neck set, to include the following, is necessary:
#3 knife handle
#15 blade
Adson tissue forceps with and without
teeth DeBakey forceps
Halsted mosquito forceps
Reinhoff swan neck clamp (or Burlisher
clamp) Allis tissue forceps
Richardson retractor
Peanut/Kittner sponges
Double-pronged skin hooks
Mahorner retractor (alternatively, other self-retaining retractors may
be used) Bovie electrocautery, harmonic scalpel , and/or Shaw scalpel
Bipolar electrocautery forceps
If intraoperative neural monitoring is to be performed, nerve monitoring Leads and surface
electrode primed endotracheal tube
Nerve Stimulator

Anesthesia
Thyroidectomy under regional or local anesthetic may be performed safely if necessary; most cases,
however, are performed under general anesthesia with endotracheal intubation.

Positioning
The patient should be placed in a supine position with the apex of the patient’s head at the top of the
operating bed. A shoulder roll or gel pad should be placed at the level of the acromion process of the
scapula to help extend the neck. Care should be taken to avoid hyperextension of the neck, and the head
should be supported to provide maximal exposure of the surgical field without hyperextension. The
patient’s arms should be gently tucked by either side. After intubation, the bed can either be rotated 180º
from the anesthesiologists or sufficiently moved away from their machines to provide a maximal work area.
Thyroidectomy technique
The technique described refers to a capsular dissection of a thyroid lobe, which can be used for any
extent of thyroid surgery.
The literature describes a variety of techniques to perform the dissection, including sharp dissection
with vessel suture ligation, electric cautery, as well as the use of electric and ultrasonic scalpels.

Incision and exposure of the thyroid gland

The initial incision is made over the marked line as described in the preparation section. A #15 blade is used
to incise through the epidermis and dermis. Using a Shaw scalpel or monopolar cautery, dissection is
carried through the subcutaneous fat to the platysma. Once the level of the platysma has been identified
along the length of the incision, the platysma is incised. Using the double-pronged skin hooks and the Shaw
scalpel or monopolar cautery, subplatysmal flaps are elevated superiorly and inferiorly. After elevating the
subplatysmal flaps, the Mahorner or alternative self-retaining retractor may be inserted. Care should be
taken to not lacerate or damage the skin edges with the retractor. The strap muscles (sternohyoid and
sternothyroid) should then be identified. In the midline between the strap muscles, the cervical linea alba
can be identified. Once identified, bluntly dissect through this fascia.
The Harmonic scalpel or monopolar cautery can then be used to dissect through this fascia superiorly
and inferiorly along the length of the sternohyoid muscle. In cases of large goiter or neoplasm, the
strap muscles may be divided to aid exposure. Division of the strap muscles should be performed
high (cephalad), as the innervation of the strap muscles occurs more inferiorly. Just deep to this
dissection lies the thyroid gland, and overlying fascia should be easily identified.

88
 Cervical linea alba.

Releasing the superior pole

Once the thyroid gland is identified, atte ntion should be turned to a single lobe. Using the Richardson
retractors and blunt dissection, capsular dissection should be carried to the lateral aspect of the th yroid
lobe, where it meets the carotid sheath fascia. Once the lateral border of the dissection has been
performed, the carotid artery identified, blunt dissection may be carried out superiorly.
At the superior pole, care should be tak n to dissect the overlying strap muscles off of the t hyroid gland
without injuring the subcapsular vessels. Next, the cricothyroid space should be identified and
dissected. By retracting the thyroid inferiorly and medially, and using a small Richardson retractor to
retract the strap muscles superiorly and laterally, the surgeon can allow for maximal visualization of the
superior pole of the thyroid. After dissecting both laterally and medially (cricothyroid space) to the
superior pole, the superior pedicle c an be divided using either a Harmonic scalpel, clips, or ties. Care
should be taken to avoid injuring the ext ernal branch of the superior thyroid nerve.

Cricothyroid space. Exposure of the superior pole

Identifying the parathyroid glands

Once the dissection of the posterior as pect of the thyroid lobe begins, the surgeon and assistants should be vigilant
in identifying the parathyroid gla nds. The superior parathyroid gland can often be fo und cephalad to the tubercle of
Zuckerkandl and can also b e found adjacent to the superior pole. The inferior parathyroid gland is usually located in
a 1 cm radius around the inferior pole of the thyroid gland and almost al ways anterior to the plane of the recurrent
laryngeal nerve . Of note, 3-7% of patients may have supernum erary glands. After identifying the glands, they should
be carefully dissected from the thyroid and left in the thyro id bed.

Identifying the recurrent laryngeal nerve

As described in the anatomy section, slight variations in the anatomy and location of the recurrent laryngeal
nerves (RLNs) can exist. During surgery, a few anatomic landmarks can assist in identific ation of the nerves.
The Tubercle of Zuckerkandl marks the posterolateral aspect of the thyroid lobe and is most often found lateral
to the recurrent laryngeal nerve. The tubercle can be found in 80% of thyroids and when found can lead
directly to the recurrent laryngeal nerve, as 93% of the nerves are found medial to this tubercle. Mos t often,
the nerve is found in a groove between the tubercle nd the lobe of the thyroid gland.
As described before, both the left and rig ht nerve follow closely with the course of the inferior thyroid artery,
and this landmark can also help identify the n erve. Veyseller et al compared identifying the nerve from a
superior-to-inferior approach (from its insertion into the larynx) to an inferior-to-superior approach
(identification at the inferior pole) and found a lower rate of h ypoparathyroidism using the superior-to-inferior
approach for identifying the RLN. However, while this was a pro spective trial, it was not randomized and could
be confounded by both surgeon preference/experience and th e indication for the thyroidectomy. Of note, man y
variations of the anatomic relationship between the arter y and the nerves exist. Additionally, Berry’s ligame nt
can be used for identification, since the nerves are foun d in close proximity to the ligament; however, the
literature describes various anatomic relationships between the 2 structures.
Berlin described the nerve penetrating the ligament in 25% of cases; however, a recent st udy by Sasou et al
described 24 cases showing the nerve travelling posteriorly and dorsally to the ligament. The inferior thyroid
artery can also be used as a landmark for the RLN, with its close association with the pathway of the nerve.

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Again variations exist, and the branches of the inferior thyroid artery can be anterior or posterior to
the nerve, or the nerve can run in between the branches of the artery.
Once the nerve is identified anatomically, its identity and integrity may be confirmed with nerve stimulation.
A threshold value may be obtained to determine the minimum current necessary to stimulate the nerve. The
course of the nerve should be bluntly dissected using the Reinhoff or a right angle clamp.
A sufficient portion of the nerve should be dissected to ensure its safety during dissection and
removal of the thyroid gland. Of note, too extensive of a dissection of the nerve can increase the risk
of neurapraxia or injury to the nerve.

Recurrent laryngeal nerve.

Removing the thyroid gland
After identifying and stimulating the recurrent laryngeal nerve, the thyroid gland can be removed.
Berry’s ligament defines the posterolateral attachment of the thyroid gland. Blunt dissection can be
used to further expose this fascial attachment. Then a harmonic scalpel can be used to transect the
ligament. Often, a minimal amount of thyroid tissue is left adjacent to the entrance of the recurrent
laryngeal nerve into the larynx, to reduce the risk of injuring the nerve. If the patient is undergoing a
total thyroidectomy, attention should first be turned to the opposite thyroid lobe and recurrent
laryngeal nerve. Once the entire specimen has been dissected and is only attached posteriorly to the
pretracheal fascia, it can be removed. The removed specimen should be inspected.

Closure
Obtaining hemostasis in the thyroid bed is imperative. This is best performed with selective bipolar
cautery, especially in the vicinity of the recurrent laryngeal nerve. A thin layer of thrombin mesh may
be applied to the superior aspect of the bed. The usage of drains is controversial and the authors do
not feel that they are routinely necessary. Note that drain usage does not replace meticulous
hemostasis nor prevent hematoma accumulation. If a large defect or void exists following
thyroidectomy, especially in patients with large goiters, a suction drain may be placed. The neck is
then closed in a layered fashion with special attention to a meticulous skin closure.
Thyroid lobectomy performed using the described technique.

Alternative techniques/methods: minimally invasive video-assisted thyroidectomy

The current standard surgical technique was developed by Miccoli at the University of Pisa and brought to North
America by Terris et al. The approach uses endoscopes and endoscopic instrumentation through a 15-20
incision. Current authors indicate a steep learning curve associated with the technique, as well as the
need for a second assistant in the procedure; however, Miccoli did demonstrate a significant reduction in
operative time after 30 cases.Careful patient selection is required to ensure feasibility of this approach.

Alternative techniques/methods: robotic-assisted thyroidectomy

With the increasing prevalence of robotic surgery programs, more varied applications for the system
have been described. To avoid a neck incision for thyroidectomy, transaxillary approaches have been
described and is being used in some centers. As an extension of this approach, a transaxillary
approach using the DaVinci robotic system was devised by Kang et al. Using a 4-6 cm axillary incision
and an 8 mm medial skin incision, the surgeon introduces 4 robotic arms to perform the
thyroidectomy and then follows the same steps as a conventional thyroidectomy.
Although achieving a better cosmetic result without an incision on the neck, the technique is more invasive
with a wider dissection necessary. A total thyroidectomy through a single sided transaxillary incision
provides significant technical difficulties. With the significant expense of using a robotic system, the
operation may be cost prohibitive. Another robot-assisted technique has been described more recently
using a traditional postauricular rhytidectomy incision. This is described as a single-port technique and has
been performed in appropriately selected patients (low body mass index, no previous neck surgery, no
significant comorbidities). Terris et al described a case series with operative times ranging from 97-193
minutes and all but the first patient being performed on in an outpatient setting.
Other Considerations: substernal goiter
Some patients that present with compressive symptoms and an enlarged thyroid demonstrate
substernal extension of their goiter either on physical examination, ultrasound, or CT imaging.

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The technique and approach for removing these goiters is very similar to a conventional thyroidectomy.
Because the goiters originate in the neck, they rarely have a mediastinal blood supply. Most often, removing
substernal goiters does not require a sternotomy; instead, they can be removed by digital dissection along
the thyroid capsule. These patients are at an increased risk of recurrent laryngeal nerve injury, with reports
as high as 17.5%. Randolph et al found that sternotomy was indicated in patients who had superior vena
cava syndrome, a goiter with mediastinal blood supply, a posterior mediastinal goiter, a larger diameter to
the intrathoracic component, recurrent substernal goiters, malignancy extending into the mediastinum, or
the presence of significant adhesions to mediastinal vessels or pleura.

Other considerations: reoperative/revision thyroid surgery

In patients who initially had a hemithyroidectomy for a follicular adenoma seen on fine-needle
aspiration, a chance exists that the surgical specimen pathology will yield a follicular
adenocarcinoma. Additionally, with the prevalence of subtotal thyroidectomy until the 1970s, a
population of patients may need reoperative thyroidectomy for recurrent benign or malignant
conditions. Additionally, patients may need revision thyroid surgery if they present with paratracheal,
central compartment, or lateral neck nodes. One of the significant challenges presented by a
reoperative or revision surgery is the scarring present from the prior violation of the neck.
For patients needing completion thyroidectomy, some surgeons advocate for early intervention within 5-7
days after the first operation, before significant inflammation and scarring occur in the surgical bed. Others
argue that the surgery should occur 2-3 months later when induration in the area is reduced.
A preoperative evaluation including imaging and reviewing previous operative reports can help with
surgical planning. Ultrasound can help localize recurrent disease or suspicious masses, while a CT scan or
MRI can give better delineation of surgical planes. As mentioned before, the use of CT scanning with
contrast should be discussed with the multidisciplinary team if radioactive iodine may be used
postoperatively. If significant scarring exists, one can consider using a trap door technique, in which
dissection is carried from the lateral border of the thyroid medially to the central compartment.
The parathyroid glands as well as the recurrent laryngeal nerves are especially at risk during revision thyroid
surgery. Care should be taken to not avulse the vasculature of the parathyroids, and the inferior thyroid artery
branches should be ligated one by one and not together to avoid injuring the branches supplying the
parathyroids. Additionally, the surgeon should be prepared to autoimplant parathyroid tissue should an avulsion
occur. Terris et al describes a population of 321 patients undergoing reoperative surgery under experienced hands
for benign thyroid disease. In this population, no patient suffered transient or permanent RLN injury from the
reoperative surgery and one patient had temporary hypoparathyroidism. In a review by Ruggiero and Fedok, the
complication rates for reoperation for both well-differentiated thyroid cancer as well as medullary thyroid cancer
were described and found to be higher. Although generally regarded as safe, and with the suggestion that
intraoperative nerve monitoring may provide benefit, the overall complication rates were directly correlated to the
degree of aggressiveness with the second operation.

Other considerations: parathyroid autoimplantation

In the event of accidental avulsion of a parathyroid gland or compromising its blood supply, the
effected parathyroid gland should be removed and placed within a specimen cup on ice. A portion of
the removed tissue should be sent for frozen section to confirm it to be in fact parathyroid tissue. The
surgeon should then consider auto-implantation of the gland.
The parathyroid gland specimen should be minced into small 1-2 mm pieces and placed in a muscular
pocket. Auto-implantation is described in the forearm or the sternocleidomastoid muscle. When
implanting into the sternocleidomastoid muscle, a small pocket should be made within the muscle
fibers. A nonabsorbable radio-opaque marker, such as a surgical clip, can be used to identify this
location in the event of future surgical intervention.

SOFT TISSUE SARCOMA OF LIMBS

-Dr. Jainendra K. Arora, Dr. Swapnil Kushwaha

INTRODUCTION
Sarcomas constitute a heterogeneous group of rare solid tumors of mesenchymal cell origin with distinct
clinical and pathological features; usually they are divided into two broad categories:Sarcomas of soft
tissue (including fat, muscles, nerve and nerve sheath, blood vessels, and other connective tissues)
· Sarcomas of bone
Soft tissue sarcomas collectively account for approximately 1% of all malignancies and 15% of
paediatric malignancies.STS, diagnosed at an early stage, is eminently curable. When diagnosed at
the time of extensive local or metastatic disease, it is rarely curable. STS become more common with
increased age, and the median age at diagnosis is 65 years.

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However, the median age varies significantly by histologic type and subtype. The annual international
incidence rates of STS range between 1.4 and 5.0 cases per 100,000. Incidence patterns vary considerably
by histologic type and subtype and incidence for most types of STS increases progressively with age.

ETIOLOGY & RISK FACTORS:

Most soft tissue sarcomas are believed to be sporadic, however small proportion of cases have
associated predisposing factors, which are:
Genetic cancer syndromes
Radiation
Lymphedema
Trauma
Chemical agents

Genetic cancer syndromes with predisposition to STS:

Familial adenomatous polyposis (FAP): Desmoid tumors occur in patients with FAP, a disorder
caused by germline mutations in the adenomatous polyposis coli (APC) gene.
Neurofibromatosis (NF): Malignant peripheral nerve sheath tumors (mPNST) develop in
neurofibromas in patients with germline mutations in the neurofibromatosis 1 (NF1) gene.
Li-Fraumeni syndrome: It is usually associated with germline mutations in TP53, the gene for tumor
suppressor p53. Patients with this syndrome develop soft tissue sarcomas, most commonly
rhabdomyosarcoma, and fibrosarcoma.
Hereditary retinoblastoma (RB): Retinoblastoma tumor suppresor gene (RB 1) mutations are
associated with an increased risk of soft tissue sarcoma, most commonly leiomyosarcoma.
Carney-Stratakis syndrome: It is characterised by germline loss of function mutation in succinate
dehydrogenase gene subunits (SDH) which predisposes to paragangliomas and GIST.

Radiation associated STS:

Soft tissue sarcomas are one of the most common types of radiation-associated tumors, both in the
general population and in individuals with cancer susceptibility syndromes. The median interval
between radiotherapy and development of a radiation-associated sarcoma is 10 years. This interval
varied significantly by histologic type, with the shortest latency observed in liposarcoma (median 4.3
years) and longest in leiomyosarcoma (median 23.5 years). The most common histologic types of
radiation associated sarcomas were pleomorphic malignant fibrous histiocytoma (pMFH) (26%),
angiosarcoma (21%), fibrosarcoma (12%), leiomyosarcoma (12%), and mPNST (9%).

ANATOMIC DISTRIBUTION:
STS can occur in any site throughout the body. 41% are located in the extremities, with 29% of all
lesions occurring in the lower limb (most commonly in the thigh); 36% are intra-abdominal, divided
between visceral (21%) and retroperitoneal (15%) lesions; 10% are truncal; and 5% are head and
neck.Most common primary sites of STS are extremities.

PATHOLOGY:
Soft tissue tumors, although clinically often non-distinctive, form a varied and complex group that
may show a wide range of differentiation and are associated with distinctive therapeutic or prognostic
features. It is important to emphasize that their histogenesis is not definable. Except for subcutaneous
lipomas or benign smooth muscle tumors, there is very little evidence that these lesions arise from
their mature (differentiated) tissue counterparts. In fact, many liposarcomas arise at sites devoid of
adipose tissue, and most rhabdomyosarcomas develop in locations that lack voluntary muscle.
·As part of the World Health Organization (WHO) classification of STS, it is now recommended to
divide soft tissue tumors into four categories: benign, intermediate (locally aggressive), intermediate
(rarely metastasizing), and malignant.There are more than 50 histologic types of soft tissue sarcoma.
Benign tumors are 100-fold more common than malignant ones.
The most commonly found are liposarcoma, leiomyosarcoma, and pleomorphic malignant fibrous
histiocytoma (pMFH).
Histopathological type of STS is site dependent. The most common subtypes in the extremities are
pleomorphic malignant fibrous histiocytoma (pMFH), liposarcoma, myxofibrosarcoma, and synovial
sarcoma; in retroperitoneal and intra-abdominal sites, liposarcoma and leiomyosarcoma are the most
common types, whereas in the visceral location, gastrointestinal stromal tumors, leiomyosarcoma,
and desmoids are found almost exclusively.
STS tends to grow along fascial plane, with the surrounding soft tissue compressed to form a
pseudocapsule.
Histologic type was found to be one of the most important predictors of sarcoma-specific death;
with malignant peripheral nerve sheath tumors (mPNST) having the highest risk of mortality.
Age is also a factor in histopathology, with the translocation associated sarcomas often presenting
at an age approximately two decades earlier than the more complex sarcoma types.
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In paediatric age group embryonal rhabdomyosarcoma is most common, synovial sarcoma has a peak
incidence among individuals in their 20s and 30s, myxoid and round cell liposarcomas have a peak
incidence among those in their 30s, and well-differentiated or dedifferentiated liposarcoma,
leiomyosarcoma, pMFH, and myxofibrosarcoma are the predominant types in the older population,
with a peak incidence among those in their 50s to 60s.
Most benign tumors do not recur locally, and those that do recur usually are not locally invasive and can
be cured with complete surgical excision. Intermediate (locally aggressive) soft tissue tumors often recur
locally and are associated with a locally infiltrative growth pattern, lesions in this category do not have any
potential to metastasize but typically require wide excision with a margin of normal tissue for good local
control. Intermediate (rarely metastasizing) tumors are often locally aggressive but in addition can
occasionally give rise to distant metastases. The risk of metastasis, usually to lymph nodes or lung, is
typically less than 2%. Malignant tumors (STS), in addition to potential for local invasion and recurrence,
have a significant risk of distant metastasis, ranging in most instances from 10% to 100%, depending on
histological type and grade. Some histologically low-grade sarcomas (myxofibrosarcoma, leiomyosarcoma,
well-differentiated liposarcoma) have a metastatic risk of only 2% to 10%, but these tumor types may
progress to more aggressive tumors, acquiring a higher risk of distant spread.
Involvement of regional lymph nodes by STS is rare. Most common route of spread in soft tissue
sarcoma is hematogenous and the most common site of metastasis is lungs.
Because none of the existing grading systems are ideal and applicable to all tumor types, sarcoma
histologic type and liposarcoma subtype are generally important determinants of prognosis and
predictors of distinctive patterns of behavior. Biologic behavior is currently best predicted based on
histologic type, histologic grade, tumor size, and depth.
Liposarcoma is further classified into three biologic groups encompassing five histologic subtypes, based on
strict morphologic features and cytogenetic aberrations—well-differentiated, dedifferentiated, myxoid, round cell,
and pleomorphic. The well-differentiated and dedifferentiated subtypes are more commonly found in the
retroperitoneal location; the myxoid, round cell, and pleomorphic subtypes are usually located in the extremity.

CLINICAL FEATURES:
The presence of soft tissue sarcoma almost invariably is suggested by the development of a mass.
This mass is usually large, is often painless. Most common presentation in STS is painless mass.
Approximately one-third of the patients present with a size less than 5 cm, one-third with a size 5 to
10 cm, and one-third with a size greater than 10 cm. Size at presentation is dependent on the location
of tumor. Small tumors are located in distal extremities, larger tumors are detected in proximal
extremities and retroperitoneal STS almost always present as large asymptomatic mass.
Patients with extremity sarcoma usually present with a painless mass, often with no functional impact,
although pain is noted at presentation in up to one third of patients. Extremity sarcomas may present as a
deep venous thrombosis, particularly in patients without significant risk factors for thrombosis.
Infrequently, tumor impingement on bone or neurovascular bundles produces pain, edema, and swelling.
Delay in diagnosis is common, with the most common differential diagnosis for extremity and trunk
lesions being a hematoma or a pulled muscle.
Physical examination should include assessment of the size of the mass, its depth in relation to
superficial fascia, and its relationship to neurovascular and bony structures.

BIOPSY:
Pre-operative biopsy is required to determine the grade and histological subtype of sarcoma.
Generally, it is recommended that, any soft tissue mass that is symptomatic or enlarging, any
superficial mass that is larger than 5 cm (unless an obvious subcutaneous lipoma) and all deep-
seated masses irrespective of size should be sampled.
Inappropriate biopsy scar can turn a limb salvage surgery into amputation so outmost care should
be given when performing the biopsy. Biopsy incision or core track should be placed in a way that it
can be removed en bloc during surgery without sacrificing extra skin or any vital structure.
Ideally, the initial diagnostic procedure should be performed at the centre at which the patient will be
treated. This facilitates proper placement of the biopsy site (or incision) and also avoids the
complications and diagnostic difficulties that can arise if such biopsy samples are handled
infrequently. Limb masses are generally best sampled through a longitudinal incision so that the
entire biopsy tract can be excised at the time of definitive resection. The incision should be centered
over the mass in its most superficial location. No tissue flap should be raised, and meticulous
hemostasis should be ensured to prevent cellular dissemination by hematoma.
Tumor histologic type and grade are correctly identified in most patients and can be used to define
the optimal treatment plan and extent of surgery required for definitive therapy. Availability of large
number of immuno-histochemical (IHC) markers has contributed in better delineation of certain
sarcomas and helps in planning various neoadjuvant treatments.
The focus of the clinical evaluation is to determine the likelihood of a benign or malignant soft tissue
tumor, the involvement of muscular or neurovascular structures, and the ease with which biopsy or
subsequent excision can be performed.
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Size becomes an important feature, and definitive diagnosis depends on biopsy results and histologic
confirmation.

Role of Fine-needle aspiration biopsy (FNAB): At centers where cytopathologists have experience with
evaluation of mesenchymal tumors, fine-needle aspiration is an acceptable method of diagnosing most soft
tissue sarcomas, particularly when the results correlate closely with clinical and radiologic findings. Fine-
needle aspiration of primary tumors has a lower diagnostic accuracy rate (60%–90%) than core needle
biopsy and is often not sufficient for establishing a specific histologic diagnosis and grade. It has a limited
role in diagnosing soft tissue tumors but may be of value in the documentation of recurrence or metastatic
disease.FNA is the limited sampling and lack of tissue architecture, which degrade diagnostic accuracy. In
addition, the amount of tissue collected usually does not allow for molecular diagnostic techniques.

Role of core needle/tru-cut biopsy: For most soft tissue masses, core needle/tru-cut biopsy (USG or CT
guided) is usually preferred. Core-needle biopsy has a diagnostic accuracy of 93% and now is the preferred
modality for taking biopsy, and can be then advocated as the first step in the diagnostic armamentarium.
The high diagnostic accuracy, ease of performance, low cost, and low complication rate make this
technique attractive. Ultrasonography/CT guidance can prevent sampling of nondiagnostic necrotic or
cystic areas of the tumor and thus increase the positive yield rate. Sonography/CT guidance also permits
biopsy of tumors in otherwise inaccessible locations and tumors located near vital structures. The tissue
sample obtained from core needle biopsy is usually sufficient for several diagnostic tests, such as electron
microscopy, cytogenetic analysis, and flow cytometry. The reported complication rate for core needle
biopsy is less than 1%. If tissue is inadequate or there is any indecision, repeat core biopsy under image
guidance or an open linearly placed incisional biopsy is then indicated.

Role of incisional biopsy: Historically, an open surgical biopsy was the gold standard for achieving
adequate tissue for definitive and specific histologic diagnosis of bone or soft tissue sarcomas.
Contemporary guidelines recommend incisional biopsy when core needle biopsy cannot produce
adequate tissue for diagnosis or when findings on core needle biopsy are non-diagnostic. The
disadvantages of incisional biopsy include the need to schedule the procedure, the need for general
anesthesia, and high costs. In addition, inappropriately placed incisions can necessitate more
extensive definitive resection to encompass the biopsy site. Complication rates up to 17% have been
reported after incisional biopsies. Potential complications include hematoma, infection, wound
dehiscence, and tumor fungation, any of which can delay definitive treatment.

Role of Excisional biopsy: Excision biopsyis recommended only for small cutaneous or subcutaneous
tumors, usually smaller than 3 cm, in which a wide re-excision (if required) is usually straight forward.
However, excisional biopsy rarely provides benefits over other biopsy techniques. Excisional biopsies
should not be performed for lesions involving the hands and feet because such biopsies may complicate
definitive re-excision. For sarcomas with initial diagnosis confirmed with excisional biopsy, microscopic
residual disease has been reported in up to 69% of re-excision specimens; without re-excision, the reported
rate of local recurrence is 30% to 40% when margins are positive or uncertain.
Role of Frozen Section: In some institutions, frozen section is relied on as the diagnostic tool of
choice. For diagnosis of malignancy, frozen section is accurate, but for histopathologic subtypes and
grade, it is inferior to permanent sections of either Tru-Cut or incisional biopsy.

IMAGING:
Imaging is critical for defining the tumor size, local extent of a tumor, guiding biopsies, monitoring response
after neo-adjuvant treatment, and detecting recurrences. Imaging should be done before any biopsy attempt as it
helps in better targeting from representative area and sometimes helps pathologist in difficult situations.
MRI is usually the preferred procedure for imaging extremity soft tissue masses. MRI enhances the
contrast between tumor and adjacent structures and provides excellent three-dimensional definition
of fascial planes. MRI infrequently can predict histologic diagnosis and biologic behavior reliably. CT
is a predominantly anatomic imaging modality. Therefore, CT plays mainly a complementary role to
MRI in evaluation of the extent of tumor. MRI, with its superior soft tissue contrast resolution, is the
dominant imaging modality for the evaluation of extremity sarcomas. CT is useful for evaluation of the
tumor matrix, especially for small calcifications and the evaluation of subtle cortical involvement. MRI
is limited in the detection of small calcifications within a mass because calcium distorts the magnetic
field. CT may also be useful in patients for whom MRI is contraindicated or cannot be tolerated.
Once the diagnosis and grade are known, evaluation for sites of potential metastasis can be
performed. Lymph node metastases occur in less than 3% of adult soft tissue sarcomas. Lymph node
metastasis are present in certain histological types of childhood sarcoma. For extremity lesions, the
lung is the principal site for metastasis; for visceral lesions and some histologic types of
retroperitoneal sarcoma, the liver is the principal site. Thus, CT is the most commonly and minimally
used modality to evaluate pulmonary metastases. Patients with visceral and retroperitoneal lesions
should have their liver imaged as part of the initial abdominal CT.
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 Magnetic resonance imaging (MRI) is preferred to Computed Tomography (CT) scan in extremity
sarcoma since it has the best soft tissue discrimination and allows multiplanar imaging which helps in
planning compartmental resections in extremity sarcomas. Soft tissue delineation and contrast
enhancement are inferior in CT but it remains best alternative when MRI cannot be done. Lung is the
most common site of metastasis accounting for 80% cases therefore, a chest CT scan is typically
indicated for all patients with newly diagnosed high grade sarcomas.
For the primary intra-abdominal (retroperitoneal) and chest sarcoma, a spiral CT scan is preferable
over MRI because air-tissue interface and motion artifacts often degrade MRI quality, and spiral CT
allows both the primary and potential for metastasis to be assessed in a single study.
Newer techniques, such as 18-fluorodeoxyglucose positron emission tomography (FDG-PET), are being
used to evaluate distant metastases and, when combined with CT and conventional imaging, may improve
the diagnostic accuracy of preoperative staging. However, over-staging remains a problem in 12% of
patients and PET-CT remains limited for evaluating pulmonary metastases smaller than 1 cm. FDG-PET
lacks specificity in its ability to help distinguish between low-grade malignancies and benign entities. Role
of functional imaging like positron emission tomography (PET) scan and MR spectroscopy (MRS) is
emerging especially in post neo-adjuvant response assessment and assessment of tumor grade.
The current role of PET seems to be primarily in the identification of unsuspected sites of metastasis in
patients with recurrent high-grade tumors, given the high rate of metastatic disease in this setting. PET may
also become useful for determining early responses to systemic therapy for soft tissue sarcoma.

CLASSIFICATION:
Clinical Staging: Clinical (cTNM) staging is dependent on characteristics of T, N, and M. T is divided
into lesions of maximum dimension 5 cm or less and lesions of more than 5 cm in greatest dimension.
Tumor size can be measured clinically or radiologically. Clinical or radiological evaluation for regional
and distant metastases should be done. Metastatic disease should be described according to the
most likely sites of metastasis. In general, the minimal clinical staging workup of soft tissue sarcoma
is accomplished by axial imaging of the involved site using MRI or CT scan and by imaging of the
lungs, the most likely site for occult metastatic disease, using chest CT scans.
Pathologic Staging: Pathologic (pTNM) staging consists of the removal and pathologic evaluation of the
primary tumor and clinical/radiologic evaluation for regional and distant metastases. In circumstances
where it is not possible to obtain accurate measurements of the excised primary sarcoma specimen, it is
acceptable to use radiologic assessment to assign a pT stage using the dimensions of the sarcoma. In
examining the primary tumor, the pathologist should subclassify the lesion and assign a histopathologic
grade. Occasionally, immunohistochemistry or cytogenetics may be necessary for accurate assignment of
subtype. Assignment of grade can be affected by prior administration of chemotherapy and/or radiotherapy.

Definition of T: Although size is currently designated as ≤ 5 cm or >5 cm, particular emphasis should
be placed on providing size measurements (or even volume determinants) in sites other than the
extremity or superficial trunk. Depth is evaluated relative to the investing fascia of the extremity and
trunk. Superficialis defined as lack of any involvement of the superficial investing muscular fascia in
extremity or trunk lesions. For staging, nonsuperficial head and neck, intrathoracic, intra-abdominal,
retroperitoneal, and visceral lesions are considered to be deep lesions.
Depth is also an independent variable and is defined as follows:
Superficial – located entirely in the subcutaneous tissues without any degree of extension
through the muscular fascia or into underlying muscle.
In these cases, pretreatment imaging studies demonstrate a subcutaneous tumor without
involvement of muscle, and excisional pathology reports demonstrate a tumor located within
the subcutaneous tissues without extension into underlying muscle.
Deep – located partly or completely within one or more muscle groups within the extremity.
Deep tumors may extend through the muscular fascia into the subcutaneous tissues or even to
the skin but the critical criterion is location of any portion of the tumor within the muscular
compartments of the extremity. In these cases, pre treatment imaging studies demonstrate a
tumor located completely or in part within the muscular compartments of the extremity.
Depth is evaluated in relation to tumor size (T):
Tumor ≤ 5 cm: T1a = superficial, T1b = deepb. Tumor > 5 cm: T2a = superficial, T2b = deep

Nodal Disease: Nodal involvement is rare in adult soft tissue sarcomas. In the assigning of stage,
patients whose nodal status is not determined to be positive for tumor, either clinically or
pathologically, should be designated as N0.
Sarcomas with lymph node metastasis are:
Malignant fibrous histiocytoma
Angiosarcoma
Rhabdomyosarcoma
Clear cell sarcoma

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 Epithelial sarcoma
Synovial sarcoma

Grade:
Grade should be assigned to all sarcomas. Historically the AJCC staging system has used a four-grade system,
but within the soft tissue sarcoma staging groups this effectively functioned as a two-stage system by combining
G1/G2 (low) and G3/G4 (high). The traditional AJCC grading system based on differentiation (well, moderate, poor,
and undifferentiated) is poorly suited to soft tissue sarcoma. The two most widely employed grading systems,
French Federation of Cancer Centres Sarcoma Group (FNCLCC) and NIH system, are 3 tiered grading systems. In
accordance with the College of American Pathologists (CAP) recommendations, the French system is preferred
over the NIH system for reasons of ease of use/reproducibility and perhaps slightly superior performance. The
FNCLCC grade is determined by three parameters: tumor differentiation (histology specific), mitotic activity, and
extent of necrosis. Each parameter is scored: differentiation (1–3), mitotic activity (1–3), and necrosis (0–2) and the
scores are summed to designate grade. The NIH system is based on the evaluation of tumor histology, location
and amount of tumor necrosis.
In the era of cytoreductive neoadjuvant therapies, clinical and pathologic staging may be altered in the future.
Because pathologic staging drives adjuvant therapy decisions, patients should be restaged after neoadjuvant
therapies have been administered. Lesions initially assigned a high-grade status, after response to presurgical
treatments, may have a less ominous appearance on microscopic examination and therefore may be assigned a
lower grade than the initial designation; occasionally, the reverse situation is observed due to either sampling
error or presurgical treatment elimination of lower grade cells in these typically heterogeneous tumors.
Histologic type, grade, and tumor size and depth are essential for staging. Histologic grade of a sarcoma
is one of the most important parameters of the staging system. Accurate grading is not always possible on
the basis of needle biopsies or in tumors that have been previously irradiated or treated with chemotherapy.
The current staging system does not take into account anatomic site. However, anatomic site is
known to influence outcome, and therefore outcome data should be reported specifying site. This is
particularly applicable in sites such as head and neck and retroperitoneum, where grade (head and
neck) or size (retroperitoneum) may disproportionately drive prognosis relative to other staging
criteria in comparison with sarcomas arising elsewhere in the body.

DEFINITION OF TNM:

Primary Tumor (T)

TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
T1 Tumor 5 cm or less in greatest dimension*
T1a Superficial tumor
T1b Deep tumor
T2 Tumor more than 5 cm in greatest dimension*
T2a Superficial tumor
T2b Deep tumor
Note: Superficial tumor is located exclusively above the superficial fascia without invasion of the
fascia; deep tumor is located either exclusively beneath the superficial fascia, superficial to the fascia
with invasion of or through the fascia, or both superficial yet beneath the fascia.

Regional Lymph Nodes (N)

NX Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
N1* Regional lymph node metastasis
* Note: Presence of positive nodes (N1) in M0 tumors is considered Stage III.

Distant Metastasis (M)

M0 No distant metastasis
M1 Distant metastasis

ANATOMIC STAGE/PROGNOSTIC GROUPS:

Stage IA T1a-T1b N0 M0 G1, GX
Stage IB T2a-T2b N0 M0 G1, GX
Stage IIA T1a-T1b N0 M0 G2, G3
Stage IIB T2a-T2b N0 M0 G2
Stage III T2a-T2b N0 M0 G3
Any T N1 M0 Any G
Stage IV Any T Any N M1 Any G

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Changes in AJCC Manual 7th edition:
N1 disease has been reclassified as Stage III rather than Stage IV disease.
Grading has been reformatted from a four grade to a three-grade system as per the criteria
recommended by the College of American Pathologists.

PROGNOSTIC FACTORS IN EXTREMITY SARCOMA:

Factors that increased risk of local recurrence were age, recurrent presentation, positive margin, and
fibrosarcoma, mPNST, or leiomyosarcoma histology.
Factors that increased distant recurrence rates were large tumor size, high histologic grade, deep
location, recurrent disease at presentation, and histologic subtype of leiomyosarcoma. Liposarcoma
was associated with decreased distant recurrence compared with other histologic types.
Factors that increased the risk of disease-specific death were recurrent presentation, size greater
than 5 cm, tumor depth and grade, positive margin, and mPNST or leiomyosarcoma histology.
Prognosis is related to the site of origin, resectability, presence of metastasis, number of metastatic
sites, and histopathological features.
Grade is a dominant factor in early metastasis, but in late recurrence initial size becomes equally
important. High-grade lesions have a much greater risk of developing a distant metastasis in the first
30 months. Even low-grade lesions, however, have a slow but inexorable increase in risk of metastasis
over the long term. Prognostic factors clearly vary with time.
Bone invasion and neurovascular invasion have historicallybeen considered bad prognostic
features. Because bone invasion is relatively uncommon in soft tissue sarcoma, it has not been
uniformly included in any staging system, but it should be considered as a poor prognostic factor.
Site of disease is also a clear determinant of outcome and an important prognostic factor. Patients
with extremity and superficial trunk lesions certainly do better than patients with retroperitoneal and
visceral sarcomas. Best prognosis is seen in extremity STS and best prognostic factor of extremity
STS is grading.
Death from local recurrence is uncommon in those with extremity lesions but occurs frequently in patients
with retroperitoneal liposarcoma. Most common cause of death in extremity STS is metastasis.

MANAGEMENT:

The goals of treatment of soft tissue sarcoma are to maximize the likelihood of long-term recurrence-free
survival while minimizing morbidity and maximizing function. In the past two decades, a multimodality
treatment approach with optimal sequencing of treatments for individual patients has been shown to
improve survival. Furthermore, patients with soft tissue sarcoma treated at high-volume centers have been
shown to have improved survival and functional outcomes. Care at such centers is particularly important
for patients with high-risk and advanced disease. The overall 5-year survival rate for patients with all stages
of soft tissue sarcoma is 50% to 60%. For patients with extremity sarcomas, a multidisciplinary treatment
approach has resulted in local control rates exceeding 90% and 5-year survival rates exceeding 70%. Most
patients who die of soft tissue sarcoma die of metastatic disease, which becomes evident within 2 to 3
years of initial diagnosis in 80% of cases.

Recommendations for the management of soft tissue masses:

Soft tissue tumors that are enlarging or greater than 3 cm should be evaluated with radiologic
imaging (ultrasonography or computed tomography [CT]), and a tissue diagnosis should be made
using core needle biopsy.

Once a sarcoma diagnosis is established, obtain imaging (magnetic resonance imaging for
extremity lesions and CT for other anatomic locations) and evaluate for metastatic disease with chest
CT for intermediate- or high-grade (grade 2 or 3) or large (T2) tumors.

A wide local excision with 1- to 2-cm margins is adequate therapy for low-grade lesions and T1 tumors.

Radiation therapy plays a critical role in the management of large (T2), intermediate- or high-grade tumors.

Patients with locally advanced high-grade sarcomas or distant metastases should be evaluated for
chemotherapy.

An aggressive surgical approach should be taken in the treatment of patients with an isolated local
recurrence or resectable distant metastases.

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Management algorithm for extremity and superficial truncal soft tissue sarcoma. A: Lo w-grade sarcomas.
High-grade sarcomas. Note that although postoperative intensity-modulated radiation therapy (IMRT)
is mentioned in the algorithm, preopera tive IMRT could be used in the same types of patients. BRT,
brachytherapy; CT, computed tomograp hy; MRI, magnetic resonance imaging; Rhabdo,
rhabdomyosarcoma; RC, round cell; Pleo, pleomorphic; LS, li posarcoma.

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 Surgery:
Surgery remains the principal therapeutic modality in STS, the extent of surgery required, along with
the optimum combination of radiotherapy and chemotherapy, remains controversial. The individual
patient's clinical and pathologic characteristics-particularly the pattern of spread expected for the
patient's histologic subtype-should be used to design the most effective treatment plan.
Wide en bloc resection is used most often. Historical attempts to resect all muscle bundles from origin to
exertion have been supplanted by an encompassing resection, aiming to obtain a 1- to 2-cm margin of
uninvolved tissue in all directions. The limiting factor is usually neurovascular or, occasionally bony
juxtaposition. Because very few soft tissue sarcomas invade bone directly, only rarely does bone need to be
resected. Similarly, few soft tissue sarcomas involve the skin, and so major skin resection should be
limited. If a primary or recurrent tumor does involve the skin or if the tumor is so extensive that skin is
involved, then the surgeon should consider free flap or rotational flap closure, particularly in those patients
who are candidates for subsequent adjuvant radiation therapy.
Primary tumors with no evidence of distant metastasis are managed with surgery alone or, when
wide pathologic margins cannot be achieved because of anatomic constraints and/or the grade is
high, surgery plus radiation therapy. The type of surgical resection is determined by several factors,
including tumor location, tumor size, depth of invasion, involvement of nearby structures need for
skin grafting or autogenous tissue reconstruction, and the patient’s performance status.
In 1985, NIH developed a consensus statement recommending limb-sparing surgery for most
patients with high-grade extremity sarcomas. However, for patients with primary or recurrent tumors
that cannot be grossly resected with a limb-sparing procedure and preservation of function (<5% of
patients), amputation remains the treatment of choice.
Margin status after surgical resection has been shown to be an independent prognostic factor. The
goal of surgical resection is to achieve a complete resection because microscopically positive or
grossly positive resection margins are associated with increased risk of local recurrence and death.
If an unexpected positive margin is found on pathologic examination of the resection specimen, re-excision
should be performed. In patients with a positive margin, particularly in patients with macroscopic residual
disease, local control is unlikely even with the addition of postoperative radiation therapy.

Wide Local Excision: The preferred treatment for extremity sarcomas is wide local excision that includes resection
of the biopsy site. The goal of wide local excision is to remove the tumor with approximately 1 to 2 cm of
surrounding normal soft tissue, but narrower margins may be necessary to preserve uninvolved critical
neurovascular structures and may be adequate for patients undergoing radiation therapy. Dissection should
proceed through grossly normal tissue planes not abutting the tumor. Soft tissue sarcomas are generally
surrounded by a zone of compressed reactive tissue that forms a pseudocapsule, but this pseudocapsule should
not be used to guide resection (enucleation). If the tumor is adjacent to or displacing major neurovascular
structures, these do not need to be resected, but the adventitia or perineurium should be removed. For some
massive tumors of the extremities, wide local excision entails a radical or complete anatomic compartment
resection. Surgical clips should be placed to delineate the extent of the resection bed for patients likely to require
postoperative radiation therapy. Recent reports demonstrate encouraging results following radical en bloc
resection with vascular reconstruction in the lower extremities. While en bloc resection with vascular
reconstruction has been associated with increased rates of postoperative complications, reported local
recurrence and 5-year survival rates are similar to those for patients not requiring vessel resection. Similarly,
studies have shown acceptable functional outcomes with resection of the sciatic, tibial, and peroneal nerves with
appropriate reconstruction and rehabilitation. Bone invasion from extremity soft tissue sarcoma, which can
generally be identified using high-quality cross-sectional imaging such as MRI, has been estimated to occur in
about 5% of patients and is associated with reduced overall survival. In cases of bone invasion, bone resection is
required to obtain an adequate surgical margin and to achieve local control. Although tumor resection and repair
of skeletal defects are possible, the likelihood of postoperative complications may be increased, and functional
outcomes may be less favorable. Soft tissue sarcomas abutting bone and in the absence of frank cortical bone
penetration, periosteum was an adequate surgical margin in patients treated with wide local excision and
radiation. Soft tissue sarcomas arising in the distal extremities, particularly the hands and feet, present unique
technical challenges. While distal-extremity tumors are often detected at a smaller size (<5 cm) than proximal-
extremity tumors, resection and reconstruction techniques are often more complex for distal extremity tumors,
and preoperative planning is critical to obtain favorable functional outcomes. Identifying the proximity of the
tumor to underlying critical structures (e.g., bone, tendon, or neurovascular structures) using MRI is essential for
surgical planning. For locally advanced tumors, repair of bone defects, vascular reconstruction, tendon transfers,
and soft tissue reconstruction using regional or free flaps have resulted in good functional outcomes. Amputation
remains a reasonable option for patients with soft tissue sarcomas of the distal extremities when acceptable
oncologic or functional outcomes cannot be achieved using available limb salvage techniques. All patients
undergoing resection of extremity sarcomas should undergo physical therapy beginning immediately after
surgery and continuing until maximum function is achieved.

Locoregional Lymphadenectomy: Patients with clinically or radiologically suspicious regional nodes

should have metastases confirmed before radical lymphadenectomy.
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Ultrasound-guided fine-needle aspiration of lymph nodes in selected patients with suspicious clinical
or radiologic findings can be done. The utility of sentinel lymph node biopsy has remained
controversial despite the recognition that several histologic subtypes of high-grade sarcoma are
known to have a propensity for lymph node metastasis.
Amputation: Amputation is the treatment of choice for the 5% of patients with primary or recurrent
extremity tumors whose tumors cannot be grossly resected with limb-sparing procedures and
preservation of function. Historically, local excision of large, high-grade soft tissue sarcomas resulted
in local failure rates of 50% to 70%, even when a margin of normal tissue around the tumor was
excised; consequently, radical resection or amputation was recommended. Today, however, the
addition of radiation therapy to less radical surgical resection has made limb salvage possible in most
cases. The local recurrence rate was significantly higher in the surgery and adjuvant radiation therapy
group: 8% versus 0% in the amputation group. However, survival rates did not differ.
Amputation versus limb salvage surgery
Last three decades witnessed major shift from amputation towards limb salvage surgery for extremity STS
management. A randomized trial proved that although local recurrence is greater in those undergoing limb-
sparing operation plus irradiation than in those undergoing amputation, disease free survival is not
different. Majority of cancer centres worldwide now reports limb salvage rate of 80-90% with optimal
oncological outcomes. Amputations are now reserved only for recurrent and locally advanced tumors where
limb salvage cannot be performed. Optimal margins for extremity STS are defined as 1-2 cm margins of
grossly normal tissues all around the tumor. In few circumstances it may increase or decrease according to
histological subtypes and proximity to critical structures. Enneking described a classification system to
describe margin status. In Intralesional excision margin runs through tumor and therefore tumor remains. In
marginal excision surgical plane runs through pseudocapsule (reactive zone). Both these procedures are
associated with local recurrence rates of 40% and not recommended now.
In wide resection surgical plane remains in normal tissue but in the same compartment as the tumor
while in radical resection the tumor is removed including affected compartments. Wide resection and
radical resections are procedure of choice in limb salvage surgery. Given the choice, most but not all
patients and families would select limb salvage over amputation. With advancement in surgical and
reconstructive techniques now only few contraindications exists. Relative contraindications include
major neurovascular involvement, immature skeletal age, pathological fracture, extensive soft tissue
involvement with no reconstruction options and sarcoma in diseased limb.

Radiation Therapy:
Radiation therapy is part of the standard treatment for intermediate or high-grade extremity and trunk
wall STS either in the pre or postoperative setting. Patients with low-grade tumors or small, superficial
high-grade tumors that have been resected with adequate margins may safely avoid radiation therapy.
The standard treatment guidelines required radiation therapy after surgery for all patients with
intermediate- or high-grade tumors of any size. However, small tumors (≤5 cm) have not generally
been associated with local recurrence, and radiation therapy for such tumors may not be necessary.
The optimal mode of radiation therapy (external-beam radiation therapy [EBRT], brachytherapy, or
intensity-modulated radiation therapy [IMRT]) and timing of radiation therapy (preoperative,
intraoperative, or postoperative) have yet to be defined.
External-beam radiation therapy[EBRT] can be delivered using photons or particle beams (electrons, protons,
pions, or neutrons). Conventional fractionation is usually 1.8 to 2 Gy per day. CT is an integral part of radiation
therapy, used to define the gross tumor volume and to estimate the margin of tissue at risk for microscopic tumor
involvement. The optimal radiation margin is not well defined: a margin of 5 to 7 cm is standard, but some centers
advocate wider margins for tumors larger than 15 cm. At most institutions, the typical preoperative dose is 50 Gy
given in 25 fractions, and resection is performed 4 to 8 weeks after completion of radiation therapy to allow acute
radiation changes to subside. Postoperative radiation therapy planning is based on tumor site, tumor grade, and
surgical margins. The entire surgical scar and drain sites should be included in the field so that a near-full dose
can be administered to the superficial skin. Metallic clips placed in the tumor bed during surgery can help define
the limits of the resection and aid in radiation therapy planning. Doses of 60 to 70 Gy are usually necessary for
postoperative treatment. No consensus exists on the optimal sequence of radiation therapy and surgery. For some
radiosensitive histologic subtypes, such as myxoid liposarcoma, preoperative radiation therapy may shrink the
tumor, facilitating resection with negative margins. Furthermore, a tissue bed undisturbed by resection has better
tissue oxygenation and can be successfully treated with lower doses of radiation. In addition, preoperative
radiation fields are smaller than postoperative radiation fields and that the average number of joints included in
the field is lower with preoperative than postoperative radiation therapy, which may result in improved functional
outcome. Critics of preoperative radiation therapy cite the difficulty of pathologic assessment of margins and the
increased rate of postoperative wound complications. However, reconstructive surgical techniques with advanced
tissue transfer procedures are being used more often in these high-risk wounds and reportedly result in better
outcomes. The higher doses generally required for postoperative radiation therapy have also been shown to be
associated with greater long-term functional impairment.

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Late radiation toxic effects (e.g., fibrosis, joint stiffness, and edema) were more common with
postoperative than preoperative radiation therapy because of higher postoperative radiation doses
and larger treatment field sizes.

Brachytherapy involves the placement of multiple radioactive seeds through catheters inserted in the tumor
resection bed. The primary benefit of brachytherapy is the shorter overall treatment time of 4 to 6 days,
compared to the 4 to 6 weeks generally required for preoperative or postoperative radiation therapy
regimens. Brachytherapy can also be used for recurrent disease previously treated with external-beam
radiation therapy. Guidelines established at MSKCC recommend spacing the after loading catheters in 1-cm
increments while leaving a 2-cm margin around the surgical bed. After adequate wound healing is
confirmed, usually after the fifth postoperative day, the catheters are loaded with seeds containing iridium-
192 that deliver 42 to 45 Gy of radiation to the tumor bed over 4 to 6 days. The primary disadvantage of
brachytherapy is that it requires significant expertise, extended inpatient hospital stays, and bed rest.
Intensity-modulated radiation therapy [IMRT] delivers radiation more precisely to the tumor than external-
beam irradiation while minimizing the volume of surrounding tissues exposed to high radiation doses. The
proposed benefits of preoperative IMRT include reduced risk of postoperative wound infections because of
minimization of the dose to the skin and protection of underlying bone (e.g., femur) as a result of concave
dose distributions. In addition, the rates of post treatment edema and joint stiffness with IMRT were lower
than the expected rates with conventional radiation therapy. Local toxic effects of radiation therapy vary
according to radiation dose, field size, and timing (preoperative or postoperative). With preoperative
radiation therapy, the most frequent wound complications are wound dehiscence, wound necrosis,
persistent drainage, infection, seroma formation, ulceration, and cellulitis. Postoperative irradiation of free
flaps is often associated with wound complications, and patients should be advised that secondary surgical
repair may be necessary. Wound complication rates of 13% to 37% have been reported for preoperative
radiation therapy, compared to 5% to 20% for postoperative radiation therapy.
If catheters are loaded after the fifth postoperative day, rates of wound complications after brachytherapy
are similar to those after postoperative radiation therapy. Long-term (chronic) effects of radiation therapy
(those occurring >1 year after completion of therapy) are generally related to fibrosis/contractures,
lymphedema, neurologic injury, osteitis, and fractures, all of which can cause substantial functional
impairment. Variables associated with poorer functional outcome after radiation therapy include larger
tumors, higher doses of radiation (>63 Gy), longer radiation fields (>35 cm), poor radiation technique, neural
sacrifice, postoperative fractures, and wound complications. Additionally, complications of any kind are
less likely after treatment for upper extremity sarcoma than after treatment for lower extremity sarcoma.
Definitive radiation therapy that delivers maximal-tissue tolerance doses of radiation may be appropriate for
selected patients with unresectable soft tissue sarcomas.

Chemotherapy:
Despite improvements in local control rates, metastasis and death remain significant problems for
patients with high-risk STS. Patients considered at high risk of death from sarcoma include those
presenting with metastatic disease, localized sarcomas at non-extremity sites, or sarcomas of
intermediate- or high-grade histology larger than 5 cm.
Standard Chemotherapy: For most patients with sarcoma, results of conventional chemotherapy regimens have
been poor.The chemo sensitivity of STS varies by histological subtype. Synovial sarcoma, myxoid/round cell
liposarcoma, and uterine leiomyosarcoma are sensitive to chemotherapy, whereas pleomorphic liposarcoma,
myxofibrosarcoma, epithelioid sarcoma, leiomyosarcoma, mPNSTs, angiosarcomas, and desmoplastic round cell
tumors have intermediate sensitivity to chemotherapy. Relatively chemo resistant histological subtypes include
clear cell sarcoma, endometrial stromal sarcoma, alveolar soft part sarcoma, and extra skeletal myxoid
chondrosarcoma. Doxorubicin and ifosfamide are the two most active agents against soft tissue sarcoma. The
European guidelines recommend doxorubicin 75 mg/m2 every 3 weeks as first-line treatment for advanced
disease. Treatment duration is based on response, but a maximum of six cycles is generally recommended
because of the risk of cumulative cardio toxicity. Ifosfamide is the recommended second-line treatment and is
recommended for first-line treatment in patients with cardiac morbidity. The standard dose of ifosfamide is 9 to 10
g/m2. Synovial sarcomas have been shown to be particularly sensitive to ifosfamide. Ifosfamide-associated toxic
effects include hemorrhagic cystitis, neurotoxicity, and renal tubular acidosis. Historically, combination therapy
with doxorubicin plus ifosfamide, dacarbazine, or both has resulted in increased response rates but no
improvement in overall survival. Over the past decade, several additional chemotherapeutic agents, including
Gemcitabine, taxanes, and trabectedin, have been noted to be active against soft tissue sarcomas. The taxanes
(docetaxel and paclitaxel) have been found to be active against angiosarcomas, particularly of the face and scalp,
likely because of their potent antiangiogenic effects.
Neoadjuvant (Preoperative) Chemotherapy: The use of neoadjuvant (preoperative) chemotherapy for
soft tissue sarcomas is based on the belief that only 30% to 50% of patients respond to standard
adjuvant (postoperative) chemotherapy. The rationale for using neoadjuvant chemotherapy is that it
enables oncologists to identify patients whose disease is sensitive to a particular chemotherapy
regimen by assessing response while the primary tumor is in situ.

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Patients whose tumors do not respond to short courses of neoadjuvant chemotherapy can thus be spared
the toxic effects of prolonged adjuvant chemotherapy. Another advantage of neoadjuvant chemotherapy is
that it may shrink tumors, enabling less morbid operations. The theoretical disadvantages of neoadjuvant
chemotherapy are related to myelosuppression and potential postoperative wound healing complications. A
recent randomized study comparing three preoperative cycles of full-dose anthracycline-ifosfamide–based
chemotherapy with three preoperative plus two postoperative cycles of the same regimen in high-risk
extremity and trunk wall soft tissue sarcomas showed equivalence between the two approaches, suggesting
the possibility of limiting chemotherapy administration to the three preoperative courses, improving the
ratio between toxicity and expected benefit.
Role of chemotherapy: Apart from paediatric sarcomas, the use of adjuvant and neoadjuvant chemotherapy for
soft tissue sarcomas remains controversial. More than a dozen individual randomized trials of adjuvant
chemotherapy have failed to demonstrate improvement in disease-free or overall survival for patients with soft
tissue sarcoma. However, several limitations of these individual trials may explain the lack of observed
improvement. First, the chemotherapy regimens used were suboptimal, consisting of single-agent therapy (most
commonly with doxorubicin) and insufficiently intensive dosing schedules. Second, the patient groups were not
large enough to reveal clinically significant differences in survival rates. Finally, most studies included patients at
low risk of metastasis and death, namely those with small (<5 cm) and low-grade tumors. Because the evidence
regarding adjuvant systemic therapy for stage III soft tissue sarcoma is inconclusive, considerable variation still
exists in treatment recommendations even though patients with large, stage II or stage III soft tissue sarcomas are
at high risk for recurrence and metastasis. Chemotherapy may be considered to downstage large tumors to enable
limb-sparing procedures, particularly for tumors known to be chemo sensitive. It is likely that subsets of high-risk
patients with extremity soft tissue sarcoma defined on the basis of tumor size or histology derive significant
benefit from systemic chemotherapy.
Overall survival was not significantly improved by single agent doxorubicin, but it was improved with
doxorubicin and ifosfamide combination.

Other Systemic Therapies:

Novel Chemotherapeutic Agents: Trabectedin, a marine derived alkaloid that binds DNA, affecting transcription
and inducing the formation of DNA double-strand breaks, has shown benefit in the treatment of advanced soft
tissue sarcomas, particularly leiomyosarcoma, myxoid liposarcoma, and other translocation-related sarcomas.
Trabectedin is generally well tolerated but can be associated with prolonged and severe neutropenia,
thrombocytopenia, and hepatic toxic effects. Palifosfamide is a stabilized formulation of the active metabolite of
ifosfamide that has been reported to be better tolerated than ifosfamide. Early trials have suggested antitumor
activity comparable or superior to that of ifosfamide without nephrotoxicity.
Targeted Therapies: Several targeted agents are being investigated for the treatment of soft tissue
sarcomas. Among these are tyrosine kinase inhibitors (e.g., imatinib, sunitinib, sorafenib, and dasatinib)
that have been developed and approved for treatment of GIST. Clinical data accumulated in phase II trials
also support the use of tyrosine kinase inhibitors (e.g., imatinib, sorafenib, and sunitinib) in the
management of other advanced sarcomas. Anti–vascular endothelial growth factor antibodies such as
bevacizumab have demonstrated activity in patients with metastatic or unresectable angiosarcomas,
solitary fibrous tumor, and epithelioid hemangioendothelioma. Pazopanib is an oral angiogenesis inhibitor
that targets vascular endothelial growth factor receptors, platelet-derived growth factor receptor (PDGFR),
and c-kit. Inhibitors of the mammalian target of rapamycin pathway, including temsirolimus, Everolimus,
and ridaforolimus, have also shown activity against some soft tissue sarcomas (i.e., PEComas).
Role of Concurrent Chemo radiation Therapy:
Treatment approaches that combine systemic chemotherapy with radio sensitizers and concurrent external-beam
radiation therapy may improve disease-free survival by treating microscopic disease and enhancing the treatment
of macroscopic disease. Concurrent chemo radiation therapy with doxorubicin based regimens reportedly
produces favorable local control rates for patients with sarcoma. Concurrent chemo radiation therapy decreases
the total treatment time for patients with high-risk sarcoma. This decrease represents a substantial advantage over
current sequential combined-modality treatment approaches, for which the total duration of radiation therapy,
chemotherapy, surgery, and rehabilitation frequently exceeds 6 to 9 months.
Role of Isolated Regional Perfusion:
Isolated regional perfusion is a limb-sparing technique in which a STS is perfused with high concentrations of
tumor necrosis factor-α and melphalan under hyperthermic conditions. The technique is generally used for locally
advanced, multifocal, or locally recurrent disease; it has also served as a palliative treatment to achieve local
control for patients with distant metastases. Limb perfusion requires isolating the main artery and vein of the
perfused limb from the systemic circulation. The anatomic approach is determined by tumor site: external iliac
vessels are used for thigh tumors, femoral or popliteal vessels for calf tumors, and axillary vessels for upper
extremity tumors. The vessels are dissected, and all collateral vessels are ligated. The main artery and vein are
then cannulated and connected to a pump oxygenator similar to that used in cardiopulmonary bypass. Either a
tourniquet or an Esmarch band is applied to the limb to achieve complete vascular isolation. Chemotherapeutic
agents are then added to the perfusion circuit and circulated for 90 minutes. Systemic leakage from the perfused
limb is monitored continuously with 99Tc-radiolabeled human serum albumin injected into the perfusate, and
radioactivity above the precordial area is recorded with a Geiger counter.
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During the entire procedure, hyperthermia of the perfused limb is maintained by external heating and by warming
the perfusate to 40°C. At the end of the procedure, the limb is washed out, the cannulas are extracted, and the
blood vessels are repaired. The optimal chemotherapeutic agent in the perfusion circuit, the benefits of
hyperthermia, and the effectiveness of hyperthermic perfusion as neoadjuvant or adjuvant treatment remains
controversial. Despite these limitations, response rates from 18% to 80% and overall 5-year survival rates from
50% to 70% have been reported. Over the past 20 years, isolated perfusion for treatment of extremity sarcoma fell
out of favor for several reasons. Most notably, improved survival and decreased local recurrence rates could be
obtained with less radical therapy, including conservative surgical excision combined with radiation to allow limb
sparing in patients who were previously thought to require amputation.
Posttreatment Surveillance: Currently, post treatment surveillance is recommended for all patients
with STS based on the fact that local recurrence can be successfully treated with radical re-excision
with or without radiation therapy. The National Comprehensive Cancer Network (NCCN) recommends
a history and physical and chest CT or radiography every 3 to 6 months for 2 to 3 years after
completion of treatment. Because most cases of distant metastasis occur within 2 to 3 years of initial
diagnosis, the NCCN guidelines indicate that follow-up intervals can be lengthened to every 6 months
and imaging can be done annually during years 3 through 5.
Consideration should also be given to imaging the primary tumor site; most experts recommend that the tumor
site be evaluated every 6 months with MRI for extremity tumors or CT for intra-abdominal or retroperitoneal
tumors. Guidelines have been established for using MRI to distinguish recurrences from typical postsurgical
changes: a discrete nodule with low signal intensity on T1-weighted images and higher signal intensity on T2-
weighted images that enhances after administration of intravenous contrast material is strongly suggestive of
recurrence and should be biopsied. Ultrasonography may be an alternative to MRI or CT for assessing for
recurrence in the extremities. Recurrence is common after surgery for abdominal soft tissue sarcomas. CT is
useful for detecting recurrences at primary and distant anatomic sites in the abdomen and pelvis. After surgery,
CT every 3 to 6 months during the first 2 years and every 6 months for 3 years thereafter has been recommended.
However, today many experienced surgeons are advocating less aggressive imaging for asymptomatic patients,
particularly after a second recurrence of retroperitoneal sarcoma, arguing that there is insufficient evidence to
suggest that survival is improved by earlier detection.

Management of Recurrent Sarcoma: Up to 20% of patients with extremity sarcoma develop locally recurrent
disease, which is often accompanied by distant metastases; thus, all patients with recurrent extremity sarcoma
should undergo a full staging assessment. Patients with microscopically positive surgical margins are at
increased risk of local recurrence. In patients with locally recurrent extremity STS the median interval to local
recurrence was 16 months. The majorities of patients are treated with additional limb-sparing surgery, and
received additional adjuvant therapy. Independent prognostic factors for disease-specific survival after local
recurrence included tumor grade, local recurrence size, and local recurrence-free interval. These data indicate that
an isolated local recurrence should be treated aggressively with resection with negative margins. For patients with
extremity sarcomas, achieving negative margins on resection of recurrent disease frequently requires amputation.
However, in some patients with recurrent extremity sarcoma, function-preserving resection combined with
additional radiation therapy, with or without chemotherapy, can produce acceptable rates of local control. The
primary determinant of survival in patients with soft tissue sarcoma is the development of distant metastases.
Patients with extremity sarcomas generally develop pulmonary metastases. Less common sites of metastasis for
soft tissue sarcomas include bone (7%), liver (4%), and lymph nodes (5%–7%). Myxoid liposarcoma of the
extremity is known to metastasize to the abdomen and pelvis; therefore, staging CT of these regions must be
performed before definitive local therapy is administered.
Management of Recurrent and Distant Metastatic Sarcoma: In selected individuals with distant metastatic
disease, surgical resection of a primary soft tissue sarcoma may be appropriate as a palliative procedure.
The decision should be based on the patient’s symptoms, which often include pain; ability to achieve local
tumor control; co morbidities; anticipated morbidity of the surgical procedure; and the extent of
metastases. The most common initial site of distant metastasis of soft tissue sarcomas is the lung. Selected
patients with a limited number of pulmonary nodules (less than four nodules), long disease- free intervals,
and no endobronchial invasion may become long-term survivors after pulmonary resection; 15% to 40% of
patients with complete resection of metastatic disease confined to the lung are long-term survivors.
Favorable prognostic factors included microscopically tumor-free margins, age younger than 40 years, and
grade 1 or 2 tumor. For patients who are surgical candidates, pulmonary resection alone can be more
effective than watchful waiting, chemotherapy, or chemotherapy plus surgery.
Chemotherapy for Distant Metastatic Sarcoma: Doxorubicin, either alone or combined with other
agents, has been the primary treatment modality for patients with advanced or distant metastatic
sarcomas for several decades. Although most patients with metastatic disease are not curable, some
patients with limited disease experience stabilization of disease with multidisciplinary treatment,
which often includes surgery and radiation therapy in addition to chemotherapy. Several factors
predict better outcome for patients with recurrent metastatic sarcoma undergoing chemotherapy,
including good performance status, previous response to chemotherapy, younger age, and absence
of hepatic metastases, low-grade tumor, and long disease-free interval.

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Isolated liver metastases, if stable over several months, may be amenable to resection, radiofrequency
ablation, or chemo-embolisation. As data accumulate regarding the sensitivity of sarcoma subtypes to
particular chemotherapies, it is critical that histology driven treatment approaches be used. New
therapies are also being identified based on the unique molecular signatures of sarcomas.

Palliative Surgery:
In cases of metastatic settings a palliative resection or amputation is required in cases of bleeding,
fungation, infection or intractable pain.

Palliative Radiation Therapy:

Definitive radiation therapy can be considered when no acceptable surgical option is available (e.g., in
patients with significant medical co-morbidities). In this setting, radiation doses greater than 63 Gy yielded
superior tumor control, but doses greater than 68 Gy resulted in increased rates of major complications.

CONCLUSION:
Extremity soft tissue sarcoma is a rare but challenging clinical entity. These patients should be treated
by an experienced multidisciplinary team for best outcomes. Optimal care in patients diagnosed with
STS is provided by a team of experts (including Surgical Oncology, Medical Oncology, Radiation
Oncology, Onco-anaesthesiology, Radiology, and Physiotherapy and Rehabilitation) with experience
in dealing with these types of tumors. As these tumors mainly affects young population clinical index
of suspicion should be high as majority presents with painless mass with long standing history and
rather than managing in inappropriate way at primary health care centres patients should be referred
to speciality centres for optimal management. Quality control surgery, coupled with adjuvant
treatment when required, provides safe and effective treatment of extremity soft tissue sarcoma with a
high limb salvage rates, good loco-regional control and good long term survival.

ENTEROCUTANEOUS FISTULA
-Dr. Tarun Mittal

Enterocutaneous fistula (ECF) is an abnormal communication between the small or large bowel and
the skin. An ECF can arise from the duodenum, jejunum, ileum, colon, or rectum. Fistula can arise
from stomach and esophagus but they are very rare. It is a kind of external fistula which is one of the
rare complications of the surgery on the small or large bowel. About 95% of ECFs were postoperative,
and the ileum was the most common site of ECF [1]; 49% of fistulas were high-output, and 51% were
low-output. It is one of the complications of the surgery on the GI tract which is associated with
significant mortality (5-20%), due to associated sepsis, nutritional abnormalities, and electrolyte
imbalances. So as to reduce the chances of the same we need to understand the factor responsible
for ECF and to reduce the mortality we need to understand the pathophysiology of the ECF. We need
to follow the standard treatment guidelines for the management. Treatment of ECFs continues to be a
difficult task. It is the topic of debate since 53 BCS as how to manage such patients. Edmunds LH Jr,
et al for the first time provided the comprehensive discussion of ECF and explained about the fluid
and electrolyte imbalance, malnutrition and generalized peritonitis associated with the ECF.

ETIOLOGY
An ECF can occur as most commonly as complication following any type of surgery on the GI tract.
Indeed, more than 75% of all ECFs arise as a postoperative complication, whereas about 15-25% result
from abdominal trauma or occur spontaneously in relation to cancer, irradiation, inflammatory bowel
disease (IBD), or ischemic or infective conditions. The etiology of ECFs can thus be characterized as
postoperative, traumatic, or spontaneous.
The post operative factors which are responsible for the occurrence of ECF are disruption of anastomosis due to
various reasons, inadvertent enterotomy in patients with adhesions, when dissection can cause multiple serosal
tears and an occasional full-thickness tear, inadvertent small-bowel injury - Occurs during abdominal closure,
especially after ventral hernia repair. It can also result from diseases of the colon, such as IBD or malignancy
leading to perforation, pericolic abscess formation, patient with prior radiation therapy.
Spontaneous ECF can also occur in about 15-25% of cases. It may be due to malignancy, radiation
enteritis with perforation, intra-abdominal sepsis, IBD (e.g., Crohn disease) (3)

PROGNOSIS
ECF is a common condition in most post surgical patients with mortality is as low as 5 to 20% due to advances in
intensive care, nutritional support, antimicrobial therapy, wound care, and operative techniques.
104
Once a patient develops an ECF, the morbidity associated with the surgical procedure or the primary
disease increases, affecting the patient's quality of life, lengthening the hospital stay, and raising the
overall treatment cost. Malnutrition, sepsis, and fluid electrolyte imbalance are the primary causes of
mortality in patients with an ECF. However, patients with an ECF with favorable factors for
spontaneous closure have a good prognosis and a lower mortality.
The favorable factors includes, end fistulas (e.g., those arising from leakage through a duodenal
stump after Pólya gastrectomy), jejunal fistulas, colonic fistulas, continuity-maintained fistulas - These
allow the patient to pass stool, small-defect fistulas, long-tract fistulas. The various unfavorable
factors which can leads to ECF areforeign body, radiation, inflammation/infection/IBD, epithelialization
of the fistula tract, neoplasm, distal obstruction (FRIEND).

WORKUP
Work of the patient with ECF includes laboratory tests like TLC, serum electrolytes, Complete blood count
(CBC), total proteins, serum albumin, and globulin, serum transferrin, serum C-reactive protein level.
Imaging studies like fistulography, water soluble contrast enema in patient with low colorectal anastomosis,
CT abdomen for looking the abdominal abscess and collection. Other tests like oral administration of a non-
absorbable marker (e.g., charcoal, Congo red), methylene blue diluted in saline.
TREATMENT
The conventional therapy for an enterocutaneous fistula (ECF) in the initial phase is always
conservative. Immediate surgical therapy on presentation is contraindicated, because the majority of
ECFs spontaneously close as a result of conservative therapy. Surgical intervention in the presence of
sepsis and poor general condition would be hazardous for the patient. However, patients with an ECF
with adverse factors, such as a lateral duodenal fistula, an ileal fistula, a high-output fistula, or a
fistula associated with a diseased bowel, may require early surgical intervention.

CONSERVATIVE THERAPY
Conservative management includes rehydration, administration of antibiotics, correction of anemia, electrolyte
repletion, drainage of obvious abscess, nutritional support, control of fistula drainage, skin protection. With the
measure mentioned above spontaneous closure occurs in almost 70% of patients. Supplementing with high-
protein and high-carbohydrate nutrition is very important in such patients(4). Total parenteral nutrition (TPN) is
usually indicated with suspected gastric, duodenal, or small-bowel fistula. When the fistula output is very high,
discontinuance of oral intake is recommended because oral intake stimulates further losses of fluids, electrolytes,
and protein via the fistula. A decrease in fistula output frequently occurs with the initiation of TPN.
Enteral nutrition is the mainstay of treatment for patients with ECFs. In fistulas of the distal ileum, colon, or
duodenum, enteral nutrition should be considered and can be administered via various routes.
Conventionally, when a gastro duodenal anastomosis or closure is needed in adverse conditions, a
concomitant feeding jejunostomy is performed, so that access is available for enteral nutritional support in
case of an anastomotic leak. The other routes of administration can be via nasogastric/jejunal tubes or a
gastrostomy. High rates of feeding should be avoided to prevent hyperosmolar diarrhea. Elemental diets,
that is, nonresidue balanced diets with protein components reduced to their basic elements, are preferred.
When a tube enterostomy is performed, proper fixation is necessary to prevent complications, such as
dislodgement of the tube or antegrade migration in the gastrointestinal (GI) tract (5).

Enteral nutrition can also be administered in patients with high-output proximal jejunocutaneous or
ileocutaneous fistulas with good mucocutaneous continuity.Skin management- Irrgang et al
developed a fistula assessment guide that has aided skin management related to ECFs. (6) This guide
is based on the following characteristics:
Origin of fistula
Nature of effluent
Condition of skin
Location of fistula opening
For a high-output fistula, a pouch system is preferable to a conventional skin dressing. For a low-
output fistula, a skin barrier with a dressing or pouch is advocated.
Skin barriers like powder, paste, wafers, spray, and creams are used as skin barriers for the protection
of skin from the enteric effluents.

SURGICAL THERAPY
Patients who have ECF with adverse factors may require earlier surgical intervention. These adverse
factors include: lateral duodenal or ligament of Treitz fistula, ileal fistula, and high-output fistula,
fistula associated with diseased bowel, distal obstruction, or eversion of mucosa.
Surgical therapy should be undertaken in patients with conventional fistulas without any adverse factors if
the patient is stable, free from all sources of sepsis, and can withstand the resectional procedure needed for
fistula closure. It is also important that it be technically feasible to perform the procedure without posing a
very high risk of injury to the bowel or other important structures. Patients with an almost completely
healed wound with a fistulous opening have a good chance of responding to surgical therapy.
105
In addition to ensuring that patients are stable and free from sources of sepsis before surgical correction of
an ECF is undertaken, antibiotic prophylaxis should be performed and parenteral nutritional
supplementation provided as necessary during the preoperative and the perioperative periods to achieve
good results. Enteral feeding should be decreased to allow luminal antibiotic preparation. Antibiotic therapy
should be administered after the culture sensitivity of earlier-grown organisms has been checked (7).
Surgical procedure depends upon the site, size of fistula. Incision depends upon location of the
fistula. Surgical procedure may be resection of the fistula with anastomosis if require diversion
stomas. If an abscess or diseased bowel segments are seen, then drainage of the abscess or
resection of the diseased bowel is performed.
If the patient is too sick to tolerate a resectional procedure, then exteriorization of the bowel via ileostomy
or colostomy is carried out. Successful direct repair of an ECF using a surrounding fasciocutaneous flap
has also been reported (8). If anastomosis is performed close to a duodenojejunal flexure, then adequate
decompression by gastrostomy and feeding jejunostomy are carried out. The latter is also performed when
proximal fistula repair is undertaken (e.g., lateral duodenal fistula).

BASIC PRINCIPLES OF SURGICAL TREATMENT

The surgical procedure for intestinal fistula treatment depends on the structures involved. The basic
surgical principles for treatment of all intestinal fistulas include the following:
The procedure involves resection of the intestinal segment, fistula tract, and the adjacent part of the
involved structure
In the absence of extensive infection or inflammation, primary anastomosis of the divided intestinal
segments is done to reestablish GI continuity and repair of the involved structure to maintain function
In the presence of extensive infection or inflammation, the divided intestinal segments are exteriorized
and the surgical procedure is modulated to allow replacement or maximal preservation of function
A staged procedure is performed after the infection and inflammation subsides to re-establish GI
continuity and reconstruction of the affected structure.
If there are dense adhesions in pelvis, distal bowel can be left in situ with proximal ileotransverse
bypass (Fig 1).

Fig 1: Bypass of fistulous bowel loops that are densely adherent within the pelvic cavity by creation of
an anastomosis between the divided afferent limb and the transverse colon.

The ideal procedure for surgical treatment of enteroenteric fistulas is en-bloc resection of the involved intestinal
segment in continuity with the fistula tract. In the absence of associated infection or significant inflammation, a
primary anastomosis of healthy bowel ends can be attempted. In the presence of associated inflammation or
infection, a proximal diversion procedure with wide drainage of the abscess cavity is performed. This is followed
in 4-6 weeks with a delayed resection of the involved intestine and fistula.In the postoperative phase of surgical
therapy for an ECF, good nutritional status is essential, because healing of the tissue and anastomosis depends
on it. Antibiotic coverage is needed if the operation is performed in the presence of sepsis.
Any flare-up of sepsis increases the possibilityof breakdown of the anastomosis and of the abdominal
wall closure (leading to dehiscence). However, unnecessary use of antibiotics can lead to resistance
and should therefore be avoided
Other Interventions like use of fibrin glue and plugs for ECF has been reported to seal (9). Gel foam
embolization- Lisle et al described successful treatment of three cases of ECF with embolization of
Gel foam at the enteric opening of the fistula (10).

REFERENCES
Kumar P, Maroju NK, Kate V. Enterocutaneous fistulae: etiology, treatment, and outcome - a study from South India. Saudi J
Gastroenterol. 2011 Nov-Dec. 17(6):391-5.
Edmunds LH Jr, Williams GH, Welch CE. External fistulas arising from the gastro-intestinal tract. Ann Surg. 1960 Sep. 152:445-71
Berry SM, Fischer JE. Classification and pathophysiology of enterocutaneous fistulas. Surg Clin North Am. 1996 Oct. 76(5):1009-18.
Uba FA, Uba SC, Ojo EO. Management of postoperative enterocutaneous fistulae in children: a decade experience in a single
centre. Afr J Paediatr Surg. 2012 Jan-Apr. 9(1):40-6
Teubner A, Morrison K, Ravishankar HR, Anderson ID, Scott NA, Carlson GL. Fistuloclysis can successfully replace parenteral
feeding in the nutritional support of patients with enterocutaneous fistula. Br J Surg. 2004 May. 91(5):625-31
Martineau P, Shwed JA, Denis R. Is octreotide a new hope for enterocutaneous and external pancreatic fistulas closure?. Am J
Surg. 1996 Oct. 172(4):386-95.
Evenson AR, Fischer JE. Current management of enterocutaneous fistula. J Gastrointest Surg. 2006 Mar. 10(3):455-64.
Coughlin S, Roth L, Lurati G, Faulhaber M. Somatostatin analogues for the treatment of enterocutaneous fistulas: a systematic
review and meta-analysis. World J Surg. 2012 May. 36(5):1016-29
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 Rabago LR, Ventosa N, Castro JL, et al. Endoscopic treatment of postoperative fistulas resistant to conservative management
using biological fibrin glue. Endoscopy. 2002 Aug. 34(8):632-8
Lisle DA, Hunter JC, Pollard CW, et al. Percutaneous gelfoam embolization of chronic enterocutaneous fistulas: report of
three cases. Dis Colon Rectum. 2007 Feb. 50(2):251-6

CARCINOMA ANAL CANAL

-Dr. Rajendra, Dr. Kishore Singh

Anal cancer is a human papilloma virus (HPV) associated cancer affecting both men and women.(1) It
accounts for only 2.6% of gastro-intestinal malignancies, but incidence rates for anal cancer have been
rising on average 2.2% each year and death rates have been rising on average 2.9% each year over 2005-
2014 . An estimated 8200 new cases (2950 men and 5260 women) of anal cancer involving the anus, anal
canal, or anorectum will occur in the United States in 2017.It has been estimated that 1100 deaths due to
anal cancer will occur in the United States in 2017.(2,3) Chemo radiation is the standard treatment for
primary squamous cell cancer of anal canal. Currently 5 year survival rate is 66.9 %.( 2, 3)
ANATOMY
The anal canal is approximately 4 to 5 cm in length, extends from the anorectal junction to the anal
verge (hair-bearing skin around the anus). (4, 5, 9)

Fig. 1. Anatomy of the anal region.

Superiorly anal canal ends at the upper border of anal sphincter and puborectalis muscle of the anorectal ring.
(6,8) The one of the important macroscopic landmark is the dentate (pectinate) line composed of the anal valves
and the bases of the anal columns in the mucosa. Histologically, the mucosa can be divided into three zones. The
upper part is covered with colorectal type glandular mucosa. The middle part is the anal transitional zone, which is
covered by a transitional epithelium with varying appearances; it extends from the dentate line and on average 0.5-
1.0 cm upward. The lower part extends from the dentate line and downward to the anal verge and has formerly
been called the pecten. It is covered by modified squamous epithelium that lacks hair or glandular structures. The
perianal skin (the anal margin) is defined by the appearance of skin appendages.Anal margin tumors are tumors of
the perianal skin (defined as the skin starting at the anal verge to a 5-cm margin). (7,8)At diagnosis lymph node
involvement is seen in 30–40% of anal cancer cases while systemic spread is uncommon with distant extra-pelvic
metastases observed in 5–8% at onset.(6,10)

Fig 2-Lymphatics of anal canal

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The major lymphatics of anal canal follow 3 main pathways- Proximal anal canal and lower rectum
lymphatics drain to peri-rectal, superior haemorrhoidal nodes of inferior mesenteric system.
Lymphatics from around and above dentate line drain to internal pudendal, hypogastric, obturator
nodes of internal iliac system and lymphatics from perianal skin, anal verge, canal distal to dentate
line drain to superficial Inguinal nodes , femoral and external iliac system.(6,8)

RISK FACTORS
Age, Gender, and Race
The median age of anal cancer diagnosis is 60 years. In the United States, incidence rates are 1.5 and
2.1 cases per 100,000 persons per year among men and women, respectively. Among men, incidence
rates are highest for blacks (2.2 cases per 100,000 persons per year) and whites (1.5 cases per 100,000
persons per year) and are lowest for Asians/Pacific Islanders (0.5 cases per 100,000 persons per year).
In women, the highest incidence is among whites (2.3 cases per 100,000 persons per year) and blacks
(1.8 cases per 100,000 persons per year), and the lowest incidence is among Asians/Pacific Islanders
(0.5 cases per 100,000 persons per year).
Anal carcinoma is associated with human papilloma virus (HPV) infection (anal-genital warts); a
history of receptive anal intercourse or sexually transmitted disease; a history of cervical, vulvar, or
vaginal cancer; immunosuppression after solid organ transplantation or HIV infection; hematologic
malignancies; certain autoimmune disorders; and smoking.(11,12)

HPV
There is a strong link between viral warts in the anogenital region and anal cancer. HPV is the most
common sexually transmitted virus that affects the genital tract of males and females. Although the virus is
cleared in most people, about 1% develops genital warts. HPV-16 is the type most commonly associated
with cancer, including anal cancer.(13,14,16) A study in Denmark and Sweden ,of tumor specimens showed
that high-risk HPV DNA was detected in 84% of anal cancer specimens, with HPV-16 detected in 73% of
them.(11,13) A 2012 report from the U.S. Centre for Disease Control and Prevention estimated that 86% to
97% of cancers of the anus are attributable to HPV infection.(17) HPV types 6, 11, and 31 account for 1.4% to
4.1%, whereas HPV-18 accounts for 3.4% to 7% anal cancer cases.(18,19)

Sexual Activity
A history of receptive anal intercourse was strongly associated with the occurrence of anal cancer
among men (relative risk, 33.1), but this association was weak and was not statistically significant
among women (relative risk, 1.8) (13) . A history of receptive anal intercourse and a higher number of
lifetime sexual partners were associated with increasing incidence of anal cancer.(14,15)

Immunosuppression
Suppression of the immune system by the use of immunosuppressive drugs or HIV infection leads to increased
incidence of genital warts, anal intraepithelial neoplasia(AIN), and anal cancer, likely because of persistent HPV
infection.(20,21) Progression of AIN to anal cancer is more likely associated with immunosuppression. The
incidence rate has recently been reported to be 131 per 100,000 person-years in HIV-infected men who have sex
with men in North America. Although there is a strong association between sexual practices like receptive anal
intercourse and anal cancer, the relationship between human immunodeficiency (HIV) infection and anal cancer is
less clear. In addition, HIV-positive patients are more likely to have HPV infection, which suggests a more indirect
effect of immunosuppression rather than a direct effect of the virus.(21,22)

Smoking
Cigarette smoking is a well-known risk factor for anal cancer that is independent of sexual practices.
The risk increases 2-5 folds over that of the general population. In a population-based case-control
study, Daling and colleagues concluded that current smokers among men and women were at a
substantially higher risk for anal cancer independent of age and other risk factors (men: odds ratio,
3.9 [95% CI, 1.9- 8.0]; women: odds ratio, 3.8 [95% CI, 2.4-6.2]).(15)

RISK REDUCTION
High-grade anal intraepithelial neoplasia (AIN) can be a precursor to anal cancer, and treatment of high-grade AIN
may prevent the development of anal cancer. AIN can be identified by cytology, HPV testing, digital rectal
examination (DRE), high-resolution anoscopy, and/or biopsy. (23-27) Routine screening for AIN in high-risk
individuals such as HIV-positive patients or men who have sex with men is controversial, because randomized
controlled trials showing that such screening programs are efficacious at reducing anal cancer incidence and
mortality are lacking, whereas the potential benefits are quite large.(28,31) Most guidelines do not recommend anal
cancer screening even in high-risk individuals at this time or state that there may be some benefit with anal
cytology.(30,32) Few guidelines recommend screening for anal cancer with DRE in HIV positive individuals.(33)
For treatment one randomized controlled trial in 246 HIV-positive men who have sex with men found that
electrocautery was superior to both topical imiquimod and topical fluorouracil in the treatment of AIN overall.(34)

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HPV Immunization
A quadrivalent HPV vaccine is available and has been shown to be effective in women in preventing persistent
cervical infection with HPV- 6, -11, -16, or -18 as well as in preventing high-grade cervical intraepithelial neoplasia
related to these strains of the virus.(35-38) The vaccine has also been shown to be efficacious in young men at
preventing genital lesions associated with HPV-6, -11, -16, or -18 infection.(38) A sub study of a larger double-blind
study observed 77.5% efficacy (95% CI, 39.6–93.3) of the vaccine for the prevention of AIN and anal cancer related
to infection with HPV-6, -11, -16, or -18 in men who have sex with men.(39) These results suggest that use of the
quadrivalent HPV vaccine in men who have sex with men may reduce the risk of anal cancer in this population. A
bivalent HPV vaccine against HPV-16 and -18 is also available.(40)

PATHOLOGY
WHO Histological Classification of Tumors of the Anal Canal Epithelial tumors intraepithelial neoplasia
(dysplasia): (41)
Squamous or transitional epithelium
Glandular
Paget disease.

Squamous cell carcinoma

Adenocarcinoma
Mucinous adenocarcinoma
Small cell carcinoma
Undifferentiated carcinoma
Others
Carcinoid tumor
Malignant melanoma
Non-epithelial tumors
Secondary tumors.

Anal intraepithelial neoplasia (AIN)

Anal cancer may arise from a precursor dysplastic lesion – AIN, – also known as anal squamous intraepithelial
lesions (SILs). The prevalence of AIN in the general population is low, but higher in 30–40% of men having sex
with men (MSMs). Progression from AIN 1 and AIN 2 to AIN 3 is uncommon, as is progression from AIN 3 to
invasive malignancy in immunocompetent patients, but appears more likely in immunosuppressed patients, and is
influenced by HIV seropositivity, low CD4 count and serotype of HPV infection.
HPV-associated tumours usually retain wild-type P53, and this explains why patients with HPV-
associated tumours respond well to concurrent chemoradiotherapy.
Different types of cells in the anal canal give rise to the different histologic variations seen with these
tumors. They include epidermoid carcinoma, adenocarcinoma, melanoma, and sarcoma. Epidermoid or SCC
is the most common anal canal neoplasm, comprising 85 to 90 % of anal cancer. The term squamous cell
carcinoma applied for lesions with different histological appearance (e.g. squamous, large cell keratinising
and non keratinising and transitional cell, cloacogenic, basaloid, epithelioid, basosquamous, and
mucoepidermoid). The remaining 10 to 15 % are mainly adenocarcinoma arising from anal glands.(41,42)
Tumours of the anal margin are generally well-differentiated and often occur in men, in contrast to anal
canal tumours which are normally poorly differentiated and are more common in women. High-grade
tumours have been thought to have a worse prognosis, but this has not been confirmed in multivariate
analysis. Histological sub-classification of basaloid, transitional, spheroidal and cloacogenic cell cancers
have no additional confirmed bearing on management. Some authors report that a basaloid histological
subtype has a higher risk of developing metastatic disease. The biology and prognosis of keratinising and
non-keratinising tumours of the anal canal also appear to be similar. Verrucous carcinomas are a variant
and are sometimes described as giant condylomas or Buschke–Lowenstein tumours, which may have a
better prognosis than SCC, for whom some consider surgery the best option.(42,43)

CLINICAL PRESENTATION
The symptoms of anal cancer are nonspecific and generally relate to the size of the tumor and the
extent of infiltration. Rectal bleeding is the most common initial symptom (45% cases). Anorectal pain
or the sensation of a rectal mass is present in 30 % of patients. Other symptoms include changes in
bowel movements, including the sensation of incomplete evacuation, enlarged inguinal lymph node.
Tumors of the perianal skin, especially Bowen's disease or Paget disease, may present with pruritus
ani or a bleeding erythematous eczematoid plaque.(44,45)

DIAGNOSTIC WORK UP
Detailed history-history to assess for known risk factors, such as homosexuality and
bisexuality in men (i.e. MSM), receptive anal intercourse, HIV positivity, AIDS, intravenous drug
use, smoking and gynecology history of vulvar and vaginal cancer(45,46)

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 Clinical examination
Palpation of inguinal region(consider biopsy or FNA for suspicious nodes)

DRE –
Site, size & nature of growth,
Distance from anal verge, upper extent,
Circumferential involvement,
Anal sphincter tone
Fixity of growth and contiguous involvement of adjacent structures

Investigations (47, 48)

Proctoscopy/ anoscopy to identify any abnormalities, such as masses, nodules, ulcerations,
and/or areas of discoloration
Biopsy from the lesion to confirm diagnosis
Routine investigations- CBC, LFT, KFT
CECT chest and abdomen–toevaluate distant disease and lymph adenopathy
CT pelvis or MRI pelvis- to evaluatetumor size, involvement of local structures( anal sphincters,
vagina or prostate), LN assessment
Magnetic resonance imaging(MRI) compared with CT, of the pelvis can provide better anatomic
detail with respect to the invasion of local structures, especially the sphincter-related
musculature, and also for the evaluation of mesorectal lymph node involvement(48)
Positron emission tomography (PET) is useful in identifying the primary tumor and spread to inguinal
lymph nodes and in assessing response to therapy. In a review PET/CT resulted in a change of nodal
status in 28% of patients, with approximately half upstaged and half downstaged (49,50)
Gynaecologic examination for woman including screening for cervical
cancer HIV testing and CD4 levels if indicated

Sentinel lymph node biopsy (SLNB)Inguinal metastases in patients affected by anal cancer are an
independent prognostic factor for local failure and overall mortality. SLNB was proposed in 2000 by
John Spratt, who suggested that prophylactic groin dissection is not required, but it may be curative
in many cases for enlarged nodes or in the presence of a positive SLNB.(51) Wade et al, in a study
confirms that SLNB is a simple and feasible technique with a high detection rate (98.4%).(52)
Mistrangelo et al compared inguinal metastasis detection between PET-CT and SLNB in 27 patients.
PET-CT detected inguinal lymph nodes in 7 patients; however, SLNB confirmed metastasis in 3 of
those 7 patients. PET-CT had a sensitivity of 100%, a negative predictive value of 100%, specificity of
83%, and a positive predictive value of 43%, all of which were inferior to SLNB.(53)Biopsy by needle
aspiration is usually only performed for clinically palpable inguinal nodes or those enlarged greater
than 10 mm on CT or MRI. Sentinel lymph node biopsy (SLNB) can reveal micrometastatic spread of
disease, and may be more accurate than diagnostic imaging, but has not been properly evaluated.
STAGING
Anal tumors are staged clinically by physical examination and radiographic imaging. Anal cancers are currently
staged according the tumor, lymph node, metastasis (TNM) staging system of the American Joint Committee on
Cancer (AJCC), eighth edition (Tables 1).(54) 50% of anal carcinomas were localized at initial diagnosis; these
patients had an 80% 5-year survival rate. Approximately 29% of patients had anal carcinoma that had already
spread to regional lymph nodes at diagnosis; these patients had a 60% 5-year survival rate. The 12% of patients
presenting with distant metastasis demonstrated a 30.5% 5-year survival rate.(55)

Table 1. DEFINITIONS OF TNM (AJCC 8 edition)

Primary Tumor (T)
TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
Tis Carcinoma in situ (Bowen’s disease, high-grade squamous intraepithelial lesion (HSIL),
anal intraepithelial neoplasia II–III (AIN II–III)
T1 Tumor 2 cm or less in greatest dimension
T2 Tumor more than 2 cm but not more than 5 cm in greatest dimension
110
 T3 Tumor more than 5 cm in greatest dimension
T4 Tumor of any size invades adjacent organ(s), e.g., vagina, urethra, bladder
Note: Direct invasion of the rectal wall, perirectal skin, subcutaneous tissue, or the sphincter
muscle(s) is not classified as T4.
Tumours of anal margin and perianal skin defined as within 5cm of the anal margin are now
classified with carcinomas of the anal canal

Regional Lymph Nodes (N)

N0No regional lymph node metastasis
N1Metastasis in regional lymph node(s)
N1a Metastases in inguinal, mesorectal and / or internal iliac
nodes N1b Metastases in external iliac nodes
N1c Metastases in external iliac and in inguinal, mesorectal and/or internal iliac nodes

M0 No distant metastasis
M1 Distant metastasis
Stage grouping
Stage I T1 N0 M0
Stage IIA T2 N0 M0
Stage IIB T3 N0 M0
Stage IIIA T1, T2 N1 M0
Stage IIIB T4 N0 M0
Stage IIIC T3, T4 N1 M0
Stage IV Any T Any N M1
PROGNOSTIC FACTORS
Extra pelvic metastasis is the most adverse prognostic factor .When anal cancer is confined to pelvis lymph node
involvement; tumor size and male sex are adverse prognostic factors for loco regional control. The European
Organisation for Research and Treatment of Cancer (EORTC) 22861 study demonstrated that skin ulceration,
nodal involvement, and male sex were independent variables associated with loco regional failure rate (LRF) and
overall survival (OS) . Multivariate analysis of data from the RTOG 98-11 trial showed that male sex and positive
lymph nodes were independent prognostic factors for DFS in patients with anal cancer.(56) Male sex, positive
nodes, and tumor size greater than 5 cm were independently prognostic for worse OS. A secondary analysis of
this trial found that tumor diameter could also be prognostic for colostomy rate and time to colostomy.(57) Data
from the ACT I trial also showed that positive lymph nodes and male sex are prognostic indicators for higher local
regional failure, anal cancer death, and lower OS.(58,59)
Recent data suggest that HPV- and/or p16-positivity are prognostic for improved OS in patients with anal
carcinoma. In a retrospective study of 143 tumor samples, p16-positivity was an independent prognostic factor for
OS (HR, 0.07; 95% CI, 0.01–0.61; P = .016). Another study of 95 patients found similar results.(60,61)

Biochemical and molecular factors

Several molecular biomarkers correlate with disease-free survival in patients with anal canal
carcinoma treated with chemo radiation. Recent studies suggested that biomarkers such as p53, Ki-
67,NF-kb,5HH and GLI-1 may be associated with loco regional control or DFS.(62)
TREATMENT
In the past, anal cancer patients were routinely treated with an APR; 5-year survival was only 40% to 70%,
however, local recurrence rates were high in the tune of 27 % to 47 %, and the morbidity with a permanent
colostomy was considerable.(4) Nigro et al, in 1974, observed complete tumor regression in a small series of anal
cancer patients treated with low dose RT (30 Gy) concurrent with 5-fluorouracil (5FU) and Mitomycin C (MMC).(63)
Further studies using similar regimens and varied doses of chemo radiotherapy provided support for combined
modality treatment.(64,65) Results of several randomized trials that address the role of concurrent chemo
radiation, induction chemotherapy, maintenance chemotherapy are summarized in Table 2.
Chemoradiation
EORTC in a phase III study compared the use of chemoradiotherapy (5- FU plus mitomycin) to RT alone in
the treatment of anal cancer. Results from this trial showed that locoregional control at 5 years was 18%
higher in the chemo- radiotherapy arm and colostomy-free interval was 32 % longer.(66)In the first UKCCCR
Anal Cancer Trial (ACT I) 585 patients were randomized to either radiation alone (45 Gy of radiation over 4-5
weeks) or the same radiation regimen combined with 5FU and MMC chemotherapy. Patients who had a good
response 6 weeks after treatment received a radiation boost, whereas poor responders went on to salvage
surgery. After a median follow-up of 42 months, the chemoradiation arm had an improved local failure rate
compared with the RT alone arm (36% radiotherapy Vs. 59%; P < .0001). Chemoradiation did result in more
early morbidity (48% Vs. 39%; P 5 .03), but the late morbidity rates (42% Vs 38%; P = .39) were similar in both
groups. Updated results after 13 years of follow-up showed a survival advantage for the chemoradiation arm
but that was not statistically significant, there was also a reduction in the risk of dying from anal cancer
(HR, 0.67; 95% CI, 0.51– 0.88, P = .004). (67,68)
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 TABLE 2. Selected Randomized Trials of Chemo radiation for Anal Cancer
Trial No. Treatment arms Median Time LC,% CFS,% Colostom PFS, DFS,% OS,
f/u(mo point( y rate,% % %
nths) year)
ACT I (Northover 292 RT +/- 157 10 66 36 36 42
2010) 5FU/MMC
285 RT alone 43 26 24 36
p <.001 sig <.001 .12
EORTC 51 RT+5FU/MMC 42 5 68 58
(Bartelink 1997) 52 RT alone 52 53
p .02 .17
RTOG 87-04 146 RT+5FU/MMC 36 4 84 9 73 76
(Flam 199677) 145 RT+5FU 66 22 51 67
p .0008 .002 .003 .31
RTOG 98-11 324 RT+5FU/MMC 156 5 80 12 68 78
(Ajani 320 Induction CDDP 74 17 58 71
2008,Gunderson f/b
2012) RT+5FU/CDDP
p .089 .075 .004 .021
ACT II (James 246 RT+5FU/MMC 3 73
2013) 246 RT+5FU/CDDP 72
226 RT+5FU/MMC 73
f/b Adj
5FU/CDDP
222 RT+5FU/CDDP 74
f/b Adj
5FU/CDDP
p .70
ACCORD 03 307 Induction 50 5 70
(Peiffert 2012) total 5FU/CDDP f/b
RT(std
boost)+5FU/MM
C
Induction 82
5FU/CDDP f/b
RT(high dose
boost)+5FU/MM
C
RT(std 77
boost)+5FU/CD
DP
RT(high dose 73
boost)+5FU/CD
DP
p .067
5FU, 5-fluorouracil; ACT, Anal Cancer Trial; CDDP, cis diamminedichloroplatinum(II) (cisplatin); CFS,
colostomy-free survival; DFS, disease-free survival; EORTC, European Organization for Research and
Treatment of Cancer; F/U, follow-up; LC, local control; MMC, mitomycin C; OS, overall survival; PFS;
progression-free survival; RT, radiotherapy; RTOG, Radiation Therapy Oncology Group; UKCCCR,
United Kingdom Coordinating Committee on Cancer Research

Role of Mitomycin
RTOG 87-04/ (ECOG)1289 In a phase III Intergroup study randomized 310 patients with anal cancer to
chemoradiation with either 5FU or 5FU/ MMC. The MMC arm had a lower colostomy rate at 4 years (9%
vs 23%; P = .002). The addition of mitomycin also resulted in improved 4-year DFS (73% vs 51%; P =
.0003). But the addition of mitomycin did result in more acute toxicities, primarily neutropenia and
thrombocytopenia (P < .001). Rates of late toxicities were similar in the both groups (P = .26). (69)

Role of Cisplatin
In a intergroup phase 3 trial, RTOG 98-11 evaluated whether cisplatin was superior to mitomycin in the
treatment of anal cancer. 682 patients were randomized to 1) induction 5-FU plus cisplatin for 2 cycles
followed by concurrent chemoradiotherapy with 5-FU and cisplatin; or 2) concurrent chemoradiotherapy
with 5-FU and mitomycin. In the update of this study, chemoradiation with 5FU/ MMC resulted in better 5-
year DFS (67.8% Vs 57.8%; P =.006) and 5-year OS (78.3% Vs 70.7%; P = .026). In addition, 5-year colostomy-
free survival showed a trend towards statistical significance in MMC arm (65.0% Vs. 71.9%; P = .05.(70)

112
Results from ACCORD 03 also suggest that there is no benefit of a course of chemotherapy given prior to
chemoradiation. In this study 307 patients of anal cancer were randomized to receive induction therapy with
5-FU/cisplatin or no induction therapy followed by chemoradiotherapy (they were further randomized to
receive an additional radiation boost or not) .No differences were seen between tumor complete response,
tumor partial response, 3-year colostomy-free survival, local control, event-free survival, or 3-year OS.(71)
ACT II trial also assessed the efficacy of replacing mitomycin with cisplatin. In this study, 940 patients with
anal cancer were randomized to in a 2x2 factorial design to one of 4 groups to receive RT (50.4 Gy) and 5FU
with either MMC or cisplatin with or without 2 cycles of maintenance chemotherapy (5FU and cisplatin).
At a median follow-up of 5.1 years, no differences were observed in complete response rate in either
arm for the chemoradiotherapy comparison or in the PFS for the comparison of maintenance therapy
versus no maintenance therapy. In addition, colostomy, did not show differences based on the
chemotherapy components of chemoradiotherapy.(72) These results demonstrate that replacement of
mitomycin with cisplatin in chemo-radiotherapy does not affect the rate of complete response, nor
does administration of maintenance therapy decrease the rate of disease recurrence following primary
treatment with chemoradiotherapy in patients with anal cancer.

Cisplatin as a substitute for 5-FU was evaluated in a phase II trial, and results suggest that cisplatin
containing and 5-FU containing chemoradiotherapy may be comparable for treatment of locally advanced
anal cancer.(73) Capecitabine ( as an alternative to 5-FU) Capecitabine has been assessed as an alternative
to 5-FU in chemoradiation regimens for anal cancer.(74) A retrospective study compared 58 patients treated
with capecitabine to 47 patients treated with infusional 5-FU; both groups also received mitomycin and
radiation. No significant differences were seen in clinical complete response, 3-year locoregional control, 3-
year OS, or colostomy-free survival between the 2 groups of patients. A phase II study found that
chemoradiation with capecitabine (825 mg/m2 twice daily) and mitomycin was safe and resulted in a 6-
month locoregional control rate of 86% (95 % CI, 0.72–0.94) in patients with localized anal cancer.(75)
Role of Biologic Therapy (Cetuximab) Cetuximab is an epidermal growth factor receptor (EGFR) inhibitor, whose
anti-tumor activity is dependent on the presence of wild-type KRAS.(76,77)In a phase II study ECOG 3205 and AIDS
Malignancy Consortium 045 evaluated the safety and efficacy of cetuximab with cisplatin/5-FU and radiation in
immunocompetent (E3205) and HIV-positive (AMC045) patients with anal squamous cell carcinoma. In an analysis
of E3205, the 3 year locoregional failure rate was 21 %.The toxicities associated with the regimen were substantial,
with grade 4 toxicity occurring in 32 % of the study population and 3 treatment associated deaths(5 %), similarly
AMC045 reported substantial grade 4 toxicities.(78) The ACCORD 16 phase
trial, which was designed to assess response rate after chemoradiotherapy with cisplatin/5-FU and
cetuximab, was terminated prematurely because of extremely high rates of serious adverse
events.(79) Radiation therapy The optimal dose and schedule of RT for anal cancer also has been
evaluated in a number of studies. An increasing body of literature suggests that toxicity can be
reduced with advanced radiation delivery techniques. RTOG 98-11 study, which used conventional 3-D
RT, the rates of grade 3/4 dermatologic toxicity were 38%/0% for IMRT-treated patients compared to
43%/5% for those undergoing conventional RT.(57,80)
RTOG 0529 trial although failed to meet its primary endpoint, there were significant reductions in acute
grade 2 or greater hematologic toxicity and grade 3 or greater dermatologic and GI toxicities with IMRT.(81)

113
WHOLE PELVIS 45Gy / 25 Fr / 5 Weeks (Cone down after 30.6 Gy) FOLLOWED BY BOOST
TOTAL DOSE:
T1 - 45 Gy / 25 Fr
T2 - 54 GY / 30 Fr
T3 - 59 Gy / 32 Fr
T4 - 59 Gy / 32 Fr

Iridium 192 high dose rate source

Intraluminal – rectal applicator or
Interstitial- template
No hospitalization, 2 – 3 treatment on OPD basis
Usually for poor responders (<80% regression) after initial CTRT

Laetitia Lestrade et al, reported fourth largest population of anal cancer patients treated with
brachytherapy boost. In this study after a median interval of 32 days from initial radiotherapy, patients
underwent a low-dose rate brachytherapy boost (72.2%) or a pulsed-dose rate brachytherapy boost
(27.8%).The median brachytherapy dose was 18 Gy; the median dose of radiotherapy and
brachytherapy boost totalled 63 Gy. Five-year local control rates were 78.6% and 10-year local control
rates were 73.9%. Grade 3/4 acute toxicity rates were 11.2% and late toxicity rates were 6.3%. Overall
survival was similar to that previously reported in the literature.(82)
Role of surgery Surgery can still be an option for well-differentiated smaller tumors (<2 cm in
diameter) that have not invaded the anal margin, as long as the surgeon can attain adequate margins
without affecting sphincter function. Radical surgery should be performed if radiotherapy is
contraindicated. Patients with biopsy proven locally progressive disease after chemo radiation are
candidates for radical surgery with an APR and colostomy.(83,84)
Treatment of Anal Cancer in Patients with HIV/AIDS
Patients with HIV/AIDS have been reported to be at increased risk for anal carcinoma.(85-86) Evidence
indicates that HIV patients with anal cancer (especially those with a CD4 count of ≥200/mm3) may be treated
with the same regimen as HIV-negative patients.(87) Recently a cohort comparison of 40 HIV-positive
patients and 81 HIV-negative patients with anal canal cancer observed that local relapse rates were 4 times
higher in the HIV-positive group (62% vs. 13%) at 3 years and found significantly higher rates of severe
acute skin toxicity for patients infected with HIV.(88) However, no differences in rates of complete response
or 5-year OS were observed between the groups in that study. A recent population-based study of 6459 of
HIV infected patients, found no increase in cancer-specific mortality for anal cancer in HIV-positive
patients.(89) It is still not clear whether increased compliance with HAART is associated with better
outcomes following chemoradiotherapy for anal carcinoma.(90,91) Patients with active HIV/AIDS-related
complications may not tolerate full-dose therapy and may require dosage adjustment.

Anal Margin Cancertreatment

Patients with T1N0, well differentiated anal margin cancer, treatment should consist of wide local
excision where one-cm margins can be obtained. In the event of a positive margin, reexcision should
be attempted. If reexcision is not feasible, radiotherapy (RT) with or without 5FU-based chemotherapy
to a dose of 60 Gray (Gy) is recommended. For T2 or greater lesions, chemoradiation similar to the
treatment for anal canal cancers should be performed. (92)

Adenocarcinoma of anal canal

Adenocarcinoma of the anal canal is thought to arise in the ducts or the intramuscular anal glands,
and in the long-standing fistulas. These neoplasms affect older age groups and have no sexual
predominance. Most of these lesions are slow growing, locally aggressive, and rarely metastasize. A
wide local excision may be performed for small and well-differentiated carcinomas that have not
invaded sphincter mechanism. Otherwise, APR is indicated.(93,94)

114
FOLLOW-UP
The surveillance and follow-up treatment recommendations for anal margin and anal canal cancer are the same.
Patients are re-evaluated by DRE between 8 and 12 weeks after completion of chemo radiotherapy. Following re-
evaluation, patients are classified according to whether they have a complete remission of disease, persistent
disease, or progressive disease. Patients with persistent disease but without evidence of progression may be
managed with close follow-up (in 4 weeks) to see if further regression occurs. The National Cancer Research
Institute’s ACT II study compared different chemo radiotherapy regimens and found no difference in OS or
progression-free survival. Interestingly, 29% of patients in this trial who did not show a complete response at 11
weeks, had achieved a complete response by 26 weeks. Based on these results, the panel believes it may be
appropriate to follow patients who have not achieved a complete clinical response with persistent anal cancer for
up to 6 months after completion of radiation and chemotherapy, as long as there is no evidence of progressive
disease during this period of follow-up. Persistent disease may continue to regress even at 26 weeks post
treatment, and APR can thereby be avoided in some patients. If biopsy proven disease progression occurs, further
intensive treatment is indicated. Although a clinical assessment of progressive disease requires histologic
confirmation, patients can be classified as having a complete remission without biopsy verification if clinical
evidence of disease is absent.
These patients undergo evaluation every 3 to 6 months for 5 years, including DRE, anoscopic
evaluation, and inguinal node palpation. Annual chest, abdominal, and pelvic imaging is
recommended for 3 years for patients with slow disease regression and for those who initially had
locally advanced disease (i.e., T3/T4 tumor) or node-positive cancers.(95)

Management of metastatic disease

Approximately 10–20% of patients suffer distant relapse. The most common sites of metastatic spread
are to the paraortic nodes, liver, lungs and skin, which usually appear relatively late and in the context
of local persistence or recurrence of disease following treatment. The prognosis in this group is poor
with only 10% of patients with distant metastases surviving 2 years or more, but long-term survivors
are described. Fit patients with symptomatic metastatic or recurrent disease not amenable to surgery
should be considered for chemotherapy, usually with a combination of cisplatin and 5FU.(96,97)

TAKE HOME MESSAGE

Chemoradiation using combinations of 5-fluorouracil (5-FU) and other chemotherapeutic agents,
mainly mitomycin C (MMC) is standard of care. This approach leads to complete tumor regression in
80% to 90% of patients, with locoregional failures around 15%. The role of surgery as a salvage
treatment is reserved for persistent or recurrent disease.

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PERI-ANAL SKIN DISEASES

-Dr. Pascal D Souza

Perianal dermatoses may occur as a primary disease or secondary to systemic disorders. They may
comprise dermatoses ranging from benign eczematous processes to advanced malignancies, and it is
important to distinguish common problems from those with more serious pathology.
The perianal dermatoses have been described under the major headings of inflammatory dermatoses,
infections, and benign, premalignant, and malignant conditions. Some of the common things that a
surgeon should be aware of if a patient comes to him for symptomatology around the perianal region
in context of the above broad groups will be briefly discussed below. The most common presentation
of many of these perianal disorders is Pruritus ani, an extremely disturbing skin condition
characterized by anal itching, burning, or irritation. A list of causes of Pruritus ani is given in Table 1.

Box 1 : Common causes of Pruritus ani

Inflammatory
Allergic or irritant contact dermatitis
Endogenous eczema-Seborrheic dermatitis
Psoriasis, Lichen planus, Lichen sclerosus,Hidradenitissuppurativa, Crohn’s
disease Infections
Beta-hemolytic Streptococcus, Staphylococcus aureus
Candidiasis &dermatophytosis
Human Papilloma virus, HIV
Infestations
Pinworms
Premalignant or malignant
AIN, Bowen’ disease
Extramammary Paget disease, Anal cancer
Ano-rectal disease
Haemorrhoids, Anal fissure, Inflammatory bowel
disease Systemic
Iron deficiency anemia, Renal failure, Cholestatic,Leukemias
Treatment of Pruritus ani per se would include irrigating the anal area twice daily, avoidance of rectal
seepage by taking a high fiber diet, avoiding excessive coffee, chocolate, and hot spicy foods,
applying protective skin barrier cream including agent such as Zinc Oxide and occasionally using a
topical anti-inflammatory or an antifungal cream.

INFLAMMATORY PERIANAL DERMATOSES

Contact DermatitisContact dermatitis is an example of a very common eczematous
(inflammatory) process that can be found in the perianal region. It could be either primary
irritant or allergic contact dermatitis. Common causes of irritant contact dermatitis (ICD) in the
perianal region include gastrointestinal contents after ingestion of spicy foods or cathartics, and
simple moisture and acidic stools. Common causes of allergic contact dermatitis in the perianal
region include nonoxinol-9 used in spermicidal jellies and some condom lubricants, latex found
in condoms, and local anesthetics in suppositories for hemorrhoids.

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Clinical presentation can vary in both but there may be erythema and varying degrees of
edema, vesiculation, maceration, and oozing. Symptoms include pruritus and/or a burning
sensation in the affected area. Diagnosis relies on detailed history taking, and patch tests
can be performed, in case an allergic contact dermatitis is suspected. Treatment centers on
removal of irritant or allergen, but severe cases can be attenuated with topical or oral
corticosteroids.Hydrophobic barrier creams are also helpful for long-term prevention of
recurrences. Antihistamines can be helpful in controlling pruritus.

Seborrheic Dermatitis
Seborrheic dermatitis is a very common endogenous eczematous process affecting up to 5% of
the population and has a possible association with the yeast Malassezia furfur. This chronic
condition is characterized by greasy yellow superficial, scaly patches with a predilection for
affecting areas with hair and numerous sebaceous glands, such as the scalp, nasolabial folds,
and eyebrows, but can also occur in the intergluteal fold and perineum. These patches can be
pruritic and are often bilateral and symmetric. Diagnosis is made by clinical exam & response to
treatment which includes using selenium sulfide or ketoconazole shampoos in the perianal area
as liquid soap twice a day, followed by application of mild to mid potency, nonfluorinated
corticosteroid creams or lotions such as desonide, mometasonefuroate, hydrocortisone valerate
1-2 times a day for no more than 2 to 3 weeks. Topical antifungal creams in the azole category
such as ketoconazole, miconazoleand so on can also be used.

Psoriasis
Psoriasis is chronic, inflammatory disease of the skin that is characterized by erythematous
plaques with classic silvery scales. It typically occurs on the scalp and extensor surfaces of the
extremities (elbow and knees/shins), as well as the sacrum and intergluteal fold, but can
generalize to all locations on the body. In the inter gluteal fold, the plaques tend to be more
humid and less scaly, with more maceration and fissuring& silvery scales are rarely noticed on
perianal lesions. Nails are frequently involved. Psoriasis can also be associated with
concomitant arthritis. Patients may complain of pruritis. The diagnosis of psoriasis relies upon
clinical exam of all relevant skin sites and less frequently upon biopsy, which is usually
diagnostic. There are a wide variety of treatments but not all of them are suitable for the perianal
area. Topical application of corticosteroids is most frequently the initial therapy, but topical
vitamin D derivatives (calcipotriene), and steroid-sparing topical immunosuppressing agents
such as tacrolimus or pimecrolimus can be used.

Lichen Sclerosus et Atrophicus

Lichen sclerosus is a chronic inflammatory disease that preferentially affects the anogenital
region. Usually seen in females, perianal area may be involved, along with vulva, with thin,
wrinkled, atrophic skin, in a characteristic figure-of-eight distribution. Patients may present with
pruritus, soreness/pain, dyspareunia, urinary or bowel symptoms, or asymptomatic. Lichen
sclerosus is a scarring disease and some architectural change is common. The diagnosis is
established by a combination of the characteristic clinical and histological findings.
Complications include scarring and malignant transformation. Treatment includes potent topical
corticosteroids, tacrolimus, retinoids, oral retinoids, methotrexate & hydroxychloroquine.

Vitiligo
Vitiligo is an acquired, autoimmune dermatological disease that usually begins in childhood or young
adulthood and is characterized by depigmented macules on any part of the body. In the acrofacial
variant the affected sites are mainly over the face, upper chest, dorsal aspects of hands, feet & the
skin around orifices, including the anus. Diagnosis relies on clinical examination & finding similarly
depigmented patches in other areas of the body. Treatment for vitiligo centers on repigmentation for
improved cosmetic appearance and it is not required for perianal lesions.

Hidradenitis Suppurativa
Hidradenitis suppurativa (HS) is a chronic follicular occlusive disorder that affects the apocrine
glands in the intertriginous axillary, groin, perianal, perineal, and inframammary skin. The clinical
course is highly variable, ranging from relatively mild cases characterised by the recurrent
appearance of papules, pustules, prominent open comedones and a few inflammatory nodules to
severe cases demonstrating deep fluctuant abscesses, draining sinuses, multiple fistulous tracts,
ulcers, fibrosis and severe band-like scars. Clinical presentation is the cornerstone of diagnosis.
Bacterial cultures can be useful to exclude MRSA furunculosis. to exclude squamous cell carcinoma
(SCC) as a differential diagnosis. Treatment is challenging. Initial treatment involves topical
clindamycin, phenolization of small localized lesions and intralesional corticosteroids injection with
concomitant oral antibiotics (tetracycline, erythromycin, flucloxacillin, ciprofloxacin, and
metronidazole). Oral prednisolone, isotretinoin & antiandrogen therapy helps in some patients.
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 FDA has approved the biologic Adalimumab in the treatment of HS. In chronic disease, incision and
drainage of abscesses, marsupialization, diathermy destruction of the affected tissue, carbon dioxide
laser as well as excision of affected areas are integral in potentially curative treatment.

Crohn’s disease
Crohn’sdisease can affect any part of the gut and perianal disease may occur in up to 75–90 %
of patients Perianal area may be involved either by metastatic spread or by direct extension into
the perianal region. Clinical features include those common to most chronic diarrheal illnesses,
such as pruritus ani, skin maceration, and erosions with secondary infection. Deep,
undermined, angulated fissures with cyanotic edges and less commonly fistulae are common
features, with multiple external openings encountered all over the perianal area and buttocks,
scrotum, and thighs. Relative lack of pain, multiplicity of lesions, and eccentricity of fissures are
important pointers for the diagnosis of Crohn’s disease
Any anal lesion in a patient who is known to be suffering from Crohn’s disease is likely to bePerianal
Crohn’s, and difficulty arises when anogenital disease represents the first manifestation. Diagnosis
may be achieved based on symptoms, signs, and investigation results (e.g., radiography and biopsy)
consistent with Crohn’s disease. Anal stenosis, fecal incontinence, and carcinoma are complications.
Management includes treatment of the underlying intestinal Crohn’s disease and local measures
including soaks with potassium permanganate and aluminum acetate, potent/very potent topical
corticosteroid/antibiotic combinations, and oral antibiotics. A role has been advocated for long-term
oral metronidazole, sulfasalazine, prednisolone and azathioprine.

Vesiculobullous disorders
Vesiculobullous disorders include autoimmune disorders like Pemphigus vulgaris, Bullous
and cicatricial pemphigoid, chronic bullous dermatoses of childhood; drug induced
conditions like Steven Johnson syndrome & Toxic epidermal necrolysis; mechano bullous
disorders like epidermolysis bullosa where depending on the severity the perianal area can
also be involved. Diagnosis comes from good history and clinical examination of rest of the
skin and can be confirmed by appropriate tests including Tzanck smear, skin biopsy for
routine and immunofluorescencetesting. Treatment includes good supportive care,
prevention of trauma, topical antibiotics & steroids, parentral antibiotics, steroids &
immunosuppressives depending on the diagnosis.

INFECTIVE PERIANAL DERMATOSES

Streptococcal and Staphylococcal Dermatitis
Superficial bacterial infections of the perianal area are most often caused by group A
streptococcus and less commonly by Staphylococcus aureus and by nongroup A
streptococci.Children younger than 10 years of age most commonly affected . This perianal
dermatitis presents with pruritus, painful defecation, anal soreness and redness, and
satellite pustulosis of the buttock.Rarely, there may be a systemic presentation with fever
and rash. Examination reveals a well-defined erythematous rim, and perianal fissuring.
Diagnosis is based on clinical presentation and identification of bacteria through culturing
of the lesion or blood if bacteremic. Standard treatment for group A streptococci is oral
penicillin,amoxycillin or other antibiotics effective against gram positive bacteria.

Erythrasma
It is a relatively rare skin infection caused by Corynebacterium minutissimum that affects mainly the
intertriginous skin. It can be found in the intergluteal fold and perianal area and it presents as a light
brown patch with sharp borders of irregular contour. Fine scales can only be appreciated after
scratching or scraping the areas. Patients are generally asymptomatic. When observed under Wood's
light, the patch shows a diagnostic coral-red colored fluorescence. First-line treatment is oral
erythromycin, but topical tolnaftate, miconazole, and erythromycin are as effective.

Necrotizing Infections
Perianal area may be affected by a number of severe gangrenous and necrotizing diseases,
often as a complication of surgery and trauma. These conditions include clostridial and non-
clostridial gangrene; streptococcal cellulitis and myositis; streptococcal toxic shock syndrome;
synergistic necrotizing cellulitis; necrotizing fasciitis; Meleney’s progressive bacterial
synergistic gangrene; synergistic gangrene; and Fournier’s gangrene. The condition may
present as a primary perirectal abscess in the perineum, with pain generally being the first
symptom. Subsequently distinct dusky red erythema and necrotized area may appear in affected
tissue, with tenderness and extension to wider areas leading to fasciitis and myositis. Crepitus
is an important feature, as is the presence of a dark brown, turbid fluid without pus. Bad
prognostic factors are patients with diabetes, leukemia, old age, and delay in treatment.
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Early recognition along with immediate and aggressive treatment is essential. High-dosage
broad-spectrum antibiotic therapy should be started till results of the culture and sensitivity are
available. Rapid and extensive debridement of all affected tissue may be needed.

Perianal Tuberculosis
Perianal tuberculosis is seen where tuberculosis is common, especially developing countries. A
primary lesion is exceptional and accompanying unilateral lymphadenopathy is an important
feature. Primary lesion may present as indolent, irregular, painful ulcers, fistulae, and
abscesses. Lupus vulgaris, verrucous tuberculosis, and orificial tuberculosis cutis may also
occur. Perianal scrofuloderma (secondary skin involvement from underlying lymph node
disease) may cause diagnostic confusion.Diagnostic workup will require thorough history, good
clinical examination, smears from discharge for AFB staining & CBNAAT testing for M.
Tuberculosis, Skin biopsy which may show granulomatous inflammation and sometimes pick up
Acid fast bacilli, Mantoux test, X Ray Chest. The condition responds dramatically to anti
tubercular treatment which can sometimes used as a diagnostic test.

Candidiasis
The yeast Candida albicans can cause both candidal intertrigo found between the gluteal folds
and also a perianal dermatitis. These conditions can often be precipitated by use of oral
antibiotic agents, steroid use, and pregnancy. Intertrigo develops in moist environments,
causing pruritic, red patches with a fringe of “collarette” scale. There can also be associated
small white pustules located near the patches, as well as “satellite” erythematous macules.
Perianal candidiasis presents with pruritis ani and a more localized erythema, around the anus.
The diagnosis of both conditions relies upon clinical findings and microscopic examination of
scrapings with potassium hydroxide. Hyphae and/or pseudohyphae are diagnostic. Treatment of
both candidal intertrigo and perianal candidiasis requires topical agents like azoles and
sometimes oral antifungal agents like Ketoconazole and Fluconazole, but systemic antipruritic
medication may also sometimes be necessary.

Dermatophytoses
Tinea is dermatological infection caused by dermatophyte fungi. It has a predilection for moist
environments, but can occur almost anywhere on the body. Tinea cruris, also known as jock itch, is
most often caused by Tinea rubrum and Tinea mentagrophytes and can spread back around to the
anus. Tinea starts as a small scaling patch that spreads peripherally and clears centrally.
Upon clinical presentation it is most often pruritic, erythematous patches with elevated borders that
are serpiginous and scaling. The borders can have papules, pustules, and vesicles. Scraping of the
scale and microscopic evaluation with potassium hydroxide (KOH prep) reveals diagnostic hyphae.
Topical azole therapy or oral terbinafine are standard treatment of dermatophytic infections.

Molluscum contagiosum
Molluscum contagiosum may also involve the perianal area, with characteristic pearly,
waxy umblicated papules which in children could be fomite related or due to auto
innoculation from other sites.In adults it could be a manifestation of minor STD; sometimes
giant lesions are seen in HIV patients.Diagnosis is clinical and puncturing te lesion leads to
extrusion of molluscum bodies. Treatment is scoopin of the lesion and Trichloro acetic
acid (TCA) application or electrodessication of lesions.

Perianal Cutaneous Amoebiasis

Amoebiasis of the perianal skin is usually associated with bowel infections but, where the
disease is endemic, direct inoculation of abraded skin or operation wounds can occur.
Abscesses,fistulae, slowly extending ulcers with serpiginous cord like margins and whitish
slough with black, and foul-smelling eschar may be the presentation. Progression may be
rapid, leading to complete destruction of the perianal and sacral tissues. The diagnosis is
made by finding the Entamoeba species in a biopsy specimen from the edge of a lesion or
by examination of a fresh sigmoidoscopy swab. Treatment with metronidazole may be
dramatically effective, but in severe cases, surgery may also be required.

Pinworm infestation
Pinworm infestation is a common worm infestation mainly in children manifesting as perianal
pruritus, itchy excoriated rash and disturbed night sleep. Diagnosis comes by performing tape
test on the anal skin immediately on waking up and seeing under microscope for characteristic
eggs of Enterobius vermicularis. Treatment is by administration of albendazole, mebendazole or
pyrantel pamoate and all family members should be treated.

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 Sexually Transmitted Diseases (STDS)
Syphilis
Syphilis may present in different ways in the perianal area, and it should never be forgotten
as a possible cause of anal ulceration. Anal chancres are often mistaken for fissures and
fistulae. Bilateral lymphadenopathy is extremely rare with other perianal ulcers. Painful
syphilitic proctitis in the absence of anal lesions can occur. Moist, flat, dirty grey plaques of
condylomata lata and granulomatous gumma may affect the anal area as an ulcer, a white
plaque, or an atrophic scar. Positive Dark groundillumination(DGI) microscopy & VDRL test
confirm the diagnosis. Injection Benzathine Penicillin is drug of choice.

Granuloma inguinale
In granuloma inguinale, the initial rapidly ulcerating papule may occur in the perianal region
in homosexual males, as soft, painless lesion which bleeds easily on trauma. “Pseudo-
bubo” may be present. In the anal canal, the lesion never extends beyond the stratified
epithelium and strictures do not occur, but anal stenosis or, rarely, epitheliomatous changes
can supervene. Diagnosis is clinical and on basis of Giemsa stain of crush smear from ulcer
which reveals safety pin appearance of C.granulomatis. Doxycycline, Trimethoprim-
sulfamethoxazole and aminolycosides are therapeutic options.

Lymphogranuloma venereum
Lymphogranuloma venereum caused by Chlamydia trachomatis serovars L1, L2 or L3
can cause ulcerative proctitis and widespread vegetating and scarring lesions specially
in men who have sex with men(MSM).
Clinical diagnosis is extremely difficult and in suspected cases Nucleic acid amplification
test(NAAT) is extremely useful to confirm the diagnosis.The Frei and complement fixation
tests(antibody titer of more than 1:64) distinguish it from hidradenitis suppurativa.
Doxycycline is drug of choice and should be given for 3-4 weeks.

Condylomata acuminata
Perianal viral warts (condylomata acuminata)usually caused by Human pappiloma virus
Type 6 & 11are common in young adults.They present as flat, papular or pedunculated
cauliflower like growth. They may be extraordinarily profuse, extending into the anal
canal, especially in homosexuals or in immunocompromised subjects, with a higher
risk of progression to dysplasia and frank malignancy specially if associated with HPV
16, 18, 31, 33 & 35.Diagnosis is mainly clinical thoughbiopsy should be performed if
there is diagnostic doubt or if dysplasia is suspected. Patients with perianal warts, and
their partners, may require full STD and sometimes colorectal assessment. HPV
infection in the perianal area can be very difficult to treat. Imiquimod, podopyllin,
podofilox, Trichloroacetic acid(TCA) application & cryotherapy have been used.

Human immunodeficiency virus (HIV) infection

Perianal ulceration may occur in homosexual men with HIV/AIDS. The main causes
ofanal ulceration in HIV infected patients are hemorrhoids, fissures, sepsis (abscess,
fistula), syphilis(chancre), herpes simplex, cytomegalovirus (CMV), Epstein–Barr virus
infection, gonorrhea,and anal warts.Treatment is directed at underlying disorder apart
from ighly active anti retroviral treatment(HAART).

Herpes Simplex Virus-Induced Pyoderma Vegetans

In patients with HIV who develop chronic perianal herpes simplex virus (HSV) ulcerations,
not uncommonly we see the development of hypertrophic lesions characterized by wet,
lobulated plaques frequently covered by fibrin sheets. Histologically one may see changes
that are characteristic of HSV infection, but often the only findings are those of
pseudoepitheliomatous hyperplasia of the skin, dense inflammatory infiltrates in the dermis,
granulation tissue, and fibrosis. This condition is known as pyoderma vegetans and it can
develop not only in chronic HSV lesions, but also in any chronic ulcerative process in an
area prone to secondary bacterial infection, such as the perianal area. Unless the tumor is
destroyed by excision, ablation, or cauterization, the ulcers will heal very slowly, in spite of
using adequate anti-HSV medications. It has been described that a chronic course of broad-
spectrum antibiotics such as ciprofloxacin may help the healing process.

BENIGN DERMATOSES
Many skin lesions can present in the perianal region not belonging to the above group. They
include inherited keratodermas like Olmsted syndrome & abnormal clone of epidermal cells
like Porokeratoses.Treatment is difficult and may require topical keratolytics and emolients
and at times oral acitretin.
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 Perineal pilosebaceous unit and precursor pits associated with trapped hairs result in formation of
pilonidal cyst/sinus. Pilonidal sinus occurs in the midline, sacrococcygeal location being the most
common site. It may present as a nodule or cyst, which ruptures and becomes infected. Symptoms
include itching, pain, recurrent abscess, purulent discharge, and persistent nodule. Treatment is
symptomatic and mainly surgical. Many benign lesions are encountered in the perianal area like angiomas
and angiokeratomas. Others include basal cell papillomas, melanocytic nevi, inguino-genital epidermoid
cysts and pilar cyst .Many of these conditions can be left alone or surgically treated.

PREMALIGNANT & MALIGNANT PERIANAL DERMATOSES

Neoplasms of the perianal skin are uncommon. Diagnosis and management is challenging in
that signs and symptoms of neoplastic lesions often mimic benign conditions. A thorough
history targeted at risk factors, combined with a detailed examination & biopsy are necessary
for correct diagnosis and planning appropriate treatment.
Paget's Disease
Extramammary Paget's disease (EMPD) can be found in various locations, including the
anogenital region, where apocrine glands are found. EMPD can be primary, arising as an
intraepithelial adenocarcinoma, or secondary, due to pagetoid spread of an adjacent or
contiguous in situ or invasive neoplasm.
Median age of presentation is 60 years and patients typically complain of anal pruritus, bleeding, and
discharge. Macroscopically, anal margin Paget's disease presents as an erythematous and
eczematous rash similar to benign skin conditions. Diagnosis should be based on skin biopsies.
Histologically, Paget's disease is commonly described as an intraepithelial adenocarcinoma
characterized by presence of typical Paget's cells, appearing as large rounded vacuolated cells.In
cases of primary EMPD, the distribution of the tumour cells is homogenous, and a glandular lumen is
rarely seen. On the other hand, secondary EMPD is associated with disarrayed tumour cells, and a
glandular lumen is frequently seen.Immunohistochemistry is useful to distinguish primary EMPD from
secondary EMPD. It has been recommended that immunohistochemical staining with antibodies
against CK7, CK20, GCDFP15 and uroplakins (UPs) can be used for the differential diagnosis of
different types of EMPD. Approximately 50% of patients with anal margin Paget's disease harbor a
colorectal neoplasm mandating full colonoscopy for complete evaluation. Full assessment of the
patient includes random mapping biopsies of the entire anal margin to evaluate superficial spread of
disease that is often macroscopically not evident. Preoperative planning of surgical resection margins
should allow for a 1-cm rim of normal tissue and histologic analysis with immunostaining gives
reliable information. Once the extent of Paget's disease has been clearly demarcated, wide local
excision is the procedure of choice. Topical 5-fluorouracil has also been
used preoperatively to help define tumor margins. The high recurrence rate and the high
incidence of associated neoplasm in a patient with Paget's disease should nevertheless
prompt vigilant long-term follow-up.

Bowen's Disease
Bowen's disease is synonymous with AIN 3 and when demonstrated on pathology indicates
carcinoma in situ. The causative agent is HPV, but only the 16 and 18 HPV genotypes are
associated with high-grade AIN.Patients with anal margin Bowen's disease typically present with
minor symptoms, such as burning or pruritus. Up to a third of the patients complain of a mass
or bleeding lesion. Clinically, Bowen's disease presents as discrete, erythematous, occasionally
brown-red pigmented, noninfiltrating, scaly, or crusted plaques, which sometimes have a moist
surface or even nodules. Differential diagnosis may be extensive and confusion with different
benign dermatologic conditions like psoriasis, eczema, or leukoplakia is common. At times
presentation can be as multiple hyperpigmented, flat-topped, coalescing papules with a
cobblestone appearance, a condition known as Bowenoid papulosis. The standard treatment is
wide surgical excision. To ensure clear resection margins, a systematic four-quadrant biopsy
technique, with intraoperative frozen sections has been advocated. The frozen sections should
include intra-anal biopsies. Despite use of this technique, recurrence rates up to 30% have been
reported. When surgery is not feasible or refused, other options are available such as topical
chemotherapy (5-FU), immunomodulation (imiquimod), and phototherapy, although the latest
guidelines favor radiotherapy. It is recommended that patients with perianal dysplasia and
Bowen’s disease be followed with an anal Pap smear and, if possible, with high-resolution
anoscopy and biopsies of the transition zone.

Squamous Cell Carcinoma

SCC of the anal margin is less common than anal canal SCC, but is the most frequent tumor of
the anal margin. Bulky advanced tumors of the anal margin sometimes directly invade the canal
making definitive diagnosis of origin difficult. In these circumstances, treatment is often
designed similar to that for tumors of anal canal origin. In contrast, tumors that are limited to the
anal margin will be treated similar to cutaneous SCC elsewhere on the body.
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 Clinical presentations include pain, bleeding, palpable lump, and discharge. Typically, SCC
of the anal margin appears as an ulcerated lesion with rolled everted edges.
A significant number of patients are misdiagnosed with an anal fissure, fistula, eczema, or
hemorrhoids; therefore a biopsy is recommended for any persistent anal margin lesion not
responding to conservative therapy.When histology is obtained, precise staging will allow
categorization for treatment recommendations and prognosis. The groin should always be
examined looking for enlarged or suspicious inguinal lymph nodes. Wide local excision
(WLE) is adequate for favorable lesions analogous to resection of cutaneous SCC of other
regions of the body. Favorable tumors are well-differentiated T1 (< 2 cm) or T2 tumors for
which a minimal negative margin of 1 cm can be obtained without compromising the anal
sphincter. Approximately 60% of all anal margin tumors are amenable to treatment with
local excision. For patients with larger tumors, nodal involvement, or invasion of the
sphincter muscle, treatment with chemoradiotherapy is preferred.

Melanoma
Malignant melanoma of the anal margin is a rare condition and accounts for 2 to 4% of all
malignant anorectal neoplasms. It is the third most common site after skin and the eye and
represents 0.6 to 1.6% of all melanomas. Symptoms are nonspecific with bleeding, pain, and
mass being commonly reported. When a lesion is pigmented, melanoma is often suspected
although confusion with thrombosed hemorrhoids is reported. Amelanotic lesions consist of
30% of the lesions and are more difficult to recognize, their diagnosis depends on
demonstration of melanin pigment by immunohistochemistry.The surgical treatment of anal
melanoma is typically wide local excision unless patients have extensive sphincter involvement
and are incontinent. Overall prognosis is poor no matter the surgical approach and efforts to
improve survival with radical resection, including APR, have not shown benefit.

Suggested Readings:
McGirt LY, Martins CR. Dermatologic Diagnoses in the Perianal Area. Clinics in Colon and Rectal Surgery. 2004;17(4):241-245.
Leonard D, Beddy D, Dozois EJ. Neoplasms of Anal Canal and Perianal Skin. Clinics in Colon and Rectal Surgery.
2011;24(1):54-63. doi:10.1055/s-0031-1272824.
Hassan I,Rather PA. Perianal Dermatology. In:Benign Anorectal Disorders: A Guide to Diagnosis and
Management.Chowdri NA, Parray FQ eds. Springer ,2015 p 161-176.

MRI FOR SURGEONS

-Dr. Anjali Prakash

Magnetic resonance imaging is a method which provides in vivo anatomic images of human body with
excellent soft tissue contrast resolution. The biggest advantage of the technique is that it does not use
ionising radiation, unlike CT.MRI also has excellent soft tissue resolution and is capable of imaging in
any plane i.e. multiplanar capability.
Principle of MRI
MRI uses the inherent magnetism in the proton (which is present in abundance in body) by manipulating it by use
of a strong radio frequency pulse in presence of a strong magnetic field. The protons absorb the energy of the RF
pulse and move to a higher energy state. Once the RF pulse is switched off, hydrogen nuclei emit the absorbed
ENERGY WHICH is the MR signal, and is detected by the receiver coils in the magnet.
The signal is dependent on:
Densities of protons within different tissues
The different rates at which protons in various tissues realign themselves with the magnetic
field. This property is also called as T1 relaxation-longitudinal relaxation
Rates of signal decay or dephasing – called as T2 relaxation-transverse relaxation.
What are T1 AND T2 IMAGES?
Terms such as "T1-weighted" and "T2-weighted" are among the most overused and least understood
concepts in MR imaging. These terms are used to communicate to other physicians the type of MR
pulse sequence employed to generate a series of images.
Look at the "colour" of CSF or other fluids to determine the type of "weighting" — dark CSF means
"T1-weighting" and bright CSF means "T2-weighting". This is a simple scheme but has fallacies. There
is one sequence called T2-FLAIR sequence. The CSF signal is suppressed by an inverting pulse and
rendered black. So although it is a T2 weighted sequence, CSF looks dark.
An image can be T1 or T2 Weighted by changing certain technical parameters- time to relax (TR) or
time to echo (TE).

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 T1 weighted T2 weighted

TR Short long

TE Short long

MRI SCANNER:
It has four main components:
Main magnet –a strong magnetic field 1.5 or 3 Tesla
RF coils-to induce alternating magnetic field to induce and detect MR signal.
Gradient system-this is required to localise the signal
Computer-this does the complex mathematical calculations required for constructing an image.

SAFETY ISSUES
Although MRI does not involve ionising radiation and no serious long term effects have been noted, it
is an area of significant potential risks.
Ferromagnetic objects (containing iron, nickel and cobalt) the magnetic field in a 1.5 T magnet is
15000 times the earth’s magnetic field. The attraction of ferromagnetic objects is proportionally
stronger. The metallic object experience projectile behaviour in proximity to the magnetic field. All
patients, visitors, non MR personnel and equipment are to be screened. Most cardiac pacemakers and
aneurysm clips, cochlear implants, intraorbital metallic foreign bodies are contraindicated .MR
compatible devices are available but vigilance is to be maintained.
Most other implants or inserted devices, ivc filters, orthopaedic implants have no risk. Recently
implanted devices such as vascular stents may not be scanned for 6 weeks to allow ingrowth of
granulation tissue. Peripheral nerve stimulation and burns are potential side effects of magnetic field
gradients. Acoustic noise due to rapidly switching magnetic field and claustrophobia are other issues.
Contrast used in MRI is Gadolinium. It is safer than iodinated contrast. Reactions are rare, most are minor.
However there are reports of severe side effects with gadolinium. Some salts of gadolinium like gadodiamide
produce a serious side effect seen many years later called –nephrogenic systemic fibrosis. Gadolinium is to be
used with caution in patients with deranged KFT, and to be avoided in patients with GFR<30ml/min
APPLICATIONS OF MRI
Neurological
MRI is the optimal method of evaluation of normal and abnormal brain parenchyma. It is an extremely
sensitive modality to detect ischemia, detecting changes within minutes of the event. Pathological disorders
of bone marrow (neoplasm/inflammatory), epidural soft tissue, discs, thecal sac, spinal cord, intradural and
extradural nerves, ligaments, facet joints are appreciated to a greater degree than CT.

Abdomen
Ultrasonography remains the primary imaging modality for the evaluation of biliary system especially for
gall bladder. Magnetic resonance cholangio-pancreatography is a non invasive imaging modality that
enables visualisation of biliary ducts and pancreatic ducts, similar to PTC &ERCP. It is based on the
principle that bile and pancreatic duct fluid are static and have long T2 relaxation .therefore on T2 weighted
images these display high signal intensity and can be differentiated from blood vessels with flowing blood.
MRCP has replaced ERCP in diagnosis, especially in post operative cases where cannulation is difficult.

MR of bowel- ENTEROGRAPHY
Barium examinations have been used to study the bowel. However with the advent of CT and MRI there has
been a shift to cross sectional imaging. Cross-sectional techniques allow visualization of the entire bowel,
without overlapping bowel loops, and detection of extra luminal pathologic conditions. CT is the modality of
choice as it is fast, can be done with a single breath hold. More recently, awareness of the risks of ionizing
radiation has been increasing and there has been an emphasis on reducing patient exposure to ionizing
radiation by using alternative imaging tests .Improvements in MR software and hardware have enabled MR
imaging to assume a major role in the evaluation of the small bowel. The ability to provide cross-sectional
information combined with a lack of ionizing radiation make MR imaging well suited for small-bowel
imaging. Two techniques currently are performed: magnetic resonance (MR) enterography and MR
Enteroclysis. In enterography, large volumes of enteric contrast material are administered orally. In
enteroclysis, enteric contrast material is administered through a nasoenteric tube. There are significant
advantages to MR imaging, such as a lack of ionizing radiation and superior tissue contrast. Many small-
bowel disease processes are chronic conditions that manifest early in life. Multiple serial examinations may
be needed to assess progression of the disease, detect complications, and monitor the response to therapy.
MR imaging provides tissue contrast superior to that obtained with computed tomography (CT). The
safety profile of intravenous contrast material for MR imaging makes contrast-enhanced MR
enterography feasible in patients with contraindications to contrast-enhanced CT. In addition, many
abnormalities may be detected at MR imaging without administering intravenous contrast material.
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This may be helpful with patients who are pregnant or who have a low glomerular filtration rate and
may be at risk for developing nephrogenic systemic fibrosis.
MR imaging can demonstrate temporal changes in bowel distension during the examination by using multiphasic
techniques without ionizing radiation. It has now become the imaging modality of choice for follow up of patients
of inflammatory bowel disease-Crohn’s disease where it also demonstrates sign of activity.

MRI in rectal cancer

The two major advancements in the treatment of rectal cancer are total mesorectal excision (TME), and
neoadjuvant radiotherapy and chemotherapy. Both have dramatically changed the local recurrence and survival
rates.MRI is the most accurate tool for the local staging of rectal cancer and is a powerful tool to select the
appropriate treatment. The decision whether a patient with rectal cancer is a candidate for TME only or
neoadjuvant therapy followed by TME, is made on the findings on MRI as it demonstrates mesorectal fascia.

Renal and Adrenal

The ability of MRI to discriminate cystic from solid lesion and higher sensitivity to solid neoplastic
element is the reason of its superiority of this modality over any other in renal imaging.MRI is highly
sensitive to even microscopic amount of fat, an ability which is important in characterising adrenal
masses, especially incidentalomas. The indications for MR include workup of indeterminate
adrenal/renal lesion, IVC invasion in renal malignancy and post treatment follow up. MR is used in
cases of renal insuffiency and where ionising radiation cannot be used. It is also useful in patients
who have had severe reaction at time of previous contrast administration. Patients on regular
surveillance for RCC like Von Hippel-Lindau disease should be followed by MRI.

Prostate
Multiparametric MRI is the most sensitive and specific technique for detection of prostate cancer.
Multiparametric MRI includes routine T2 W imaging along with dynamic contrast enhanced MRI, Diffusion
weighted imaging and MR spectroscopy. A scoring system has been devised on MRI called as PIRADS
(similar to breast BIRADS) which has good correlation with histopathology in cases of prostate nodule.
These recommendations assign the level of suspicion for clinically significant prostate cancer and improve
the accuracy of multiparametric MR imaging and help triage patients to appropriate management.

MR ANGIOGRAPHY
The appearance of blood vessels on MRI depends on various factors such as technical factors (type of
pulse sequence), pulastility and range of velocities in vessels of interest, size, shape and orientation
of vessels relative to image plane. Patent vessels can appear as zones of signal void (black blood
imaging) or as zones of high signal (white blood imaging)

MR angiography (MRA)
It is a group of techniques based on (MRI) to image blood vessels. Magnetic resonance angiography is used
to generate images of arteries (and less commonly veins) in order to evaluate them for stenosis (abnormal
narrowing), occlusions, aneurysms (vessel wall dilatations, at risk of rupture) or other abnormalities. A
variety of techniques can be used to generate the pictures of blood vessels based on flow effects which can
be done without use of contrast .however body MR angiography is usually done with administration of
intravenous MR contrast-Gadolinium. An advantage of MRA compared to catheter angiography is the non-
invasive character of the examination; no catheters have to be introduced in the body. Another advantage,
compared to CT angiography and catheter angiography, is that the patient is not exposed to any ionizing
radiation. Also, contrast media used for MRI tend to be less toxic than those used for CT angiography and
catheter angiography, with fewer people having any risk of allergy. Also far less is needed to be injected
into the patient. The greatest drawbacks of the method are its comparatively high cost. Spatial resolution
i.e. ability to different two closely placed structures as separate is better with CT Angiography.MR
Angiography is a longer procedure than CT Angiography. The length of time the scans take can also be an
issue, with CT being far quicker. It is also ruled out in patients who are unsafe for MRI (such as having a
pacemaker or metal in the eyes or certain surgical clips).

Pelvic floor- MR FISTULOGRAM

The role of MRI in the evaluation of gynaecological malignancies has evolved during the past two decades.
MRI has been shown to be superior to CT in the work-up of endometrial and cervical cancer and may be a
useful problem-solving tool in the evaluation of ovarian cancer. In addition, there is evidence that MRI may
aid the differentiation of radiation fibrosis from recurrent tumour.The accuracy of MRI assessment of lymph
node invasion is similar to that of CT; both rely primarily on size criteria to detect lymph node
metastases.MRI, which provides exquisite detail of pelvic anatomy, is the most accurate imaging technique
for investigating and classifying congenital anomalies; classification is important as fertility outcomes and
surgical management vary considerably. Magnetic resonance imaging (MRI) is the best imaging modality for
preoperative assessment of patients with anal fistula. MRI helps to accurately demonstrate disease
extension and predict prognosis. This in turn helps make therapy decisions and monitor therapy.
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The role of imaging is, to outline all hidden tracts and define the relationship of the fistula to the anal
sphincter. Inadvertent damage to the anal sphincter can lead to anal incontinence; hence the
importance of knowledge of the relation between the fistula tract and the anal sphincter. Missed
extensions at surgery are usually the cause of recurrence, and adequate surgery is warranted in more
extensive disease. MRI has been shown to reduce recurrent disease and, therefore, reoperation
Musculoskeletal
The advent of MRI revolutionised the imaging of musculoskeletal structures, providing unequalled
direct assessment of soft tissues and joint.

Intraoperative MRI
Intraoperative magnetic resonance imaging (iMRI) refers to an operating room configuration that enables
surgeons to image the patient via an MRI scanner while the patient is undergoing surgery, particularly brain
surgery. iMRI reduces the risk of damaging critical parts of the brain and helps confirm that the surgery was
successful or if additional resection is needed before the patient’s head is closed and the surgery completed

Breast MRI
Mammography is the primary modality used for imaging the breast. However, it has known limitations.
Dynamic contrast-enhanced breast magnetic resonance imaging (MRI) provides superior sensitivity to
detect breast cancer and, when used in the appropriate clinical setting, it has become a useful adjunct
to mammography. Overlap in the MRI appearance of some benign and malignant diseases limits the
specificity of breast MRI. Breast MRI is indicated in the following clinical scenarios-
Preoperative evaluation of patients with newly diagnosed breast cancer,
Evaluation of breast cancer patients treated with neoadjuvant chemotherapy
Evaluation of breast cancer patients with positive surgical margins following breast
conservation therapy.
Evaluation of patients with metastatic axillary lymphadenopathy and an unknown primary malignancy.
Determination of silicone breast implant integrity, breast cancer screening in high risk women,
and the use of breast MRI as a problem-solving tool for equivocal mammographic findings.

Breast cancer staging is based on the extent of local-regional disease in the breast and axilla, which has
predictive value regarding the patient’s prognosis and dictates treatment options. Breast MRI, when
combined with mammography and clinical breast exam, has been shown to provide sensitivity of 99% for
the preoperative assessment of the local extent of disease in patients with newly diagnosed breast cancer.
This is compared with sensitivities of 50% for clinical breast exam, 60% for mammography and 83% for
ultrasound alone. Breast MRI has consistently been found to detect additional unsuspected malignancy
within the ipsilateral breast, with numerous studies identifying this in 10% to 27% of patients.
Breast MRI may be particularly helpful in certain situations like patients who have dense breast tissue,
invasive lobular carcinoma, extensive ductal carcinoma in-situ (DCIS) and those who will be treated
with neoadjuvant chemotherapy.
Dense breast tissue may obscure signs of malignancy on mammography and limit the evaluation of
the true extent of disease. Sensitivity of mammography decreases in proportion to increases in
mammographic breast density, while breast density does not affect the sensitivity of MRI.
Both invasive lobular carcinoma and tumours with an extensive component of DCIS are often underestimated by
mammography. Obtaining negative surgical margins with breast conservation therapy for these tumours is often
challenging. In the past, MRI has been considered limited in the evaluation of DCIS. However, more recent studies
have found MRI to be superior to mammography in detecting unsuspected DCIS. Thus, these patients may benefit
from more accurate assessment of the extent of disease preoperatively using MRI. The mammographic sensitivity
for detecting invasive lobular carcinoma has been reported to range from 34% to 81%, which is inversely related to
mammographic density. Conversely, the reported sensitivity of MRI for invasive lobular carcinoma is 93% to 96%.
MRI has also been found to more accurately depict tumour size when compared with pathologic specimens’ vs.
mammography and ultrasound.
Invasive lobular carcinoma is generally believed to have an increased propensity for bilateral disease.
This subset of patients should have a pre op MRI
Breast cancer screening
Screening mammography is the only imaging modality that has been proven to decrease breast
cancer mortality for the general population. Breast MRI has been shown to detect an increased rate of
small node-negative cancers in women at high risk for breast cancer and it is a useful screening tool
when used as an adjunct to mammography in high-risk women. However, due to its limited specificity
and high cost, MRI is not appropriate for screening the general population.
The ACS has recommended annual screening breast MRI for very high-risk women, which includes:
women with BRCA1and BRCA2 gene mutations and their untested first-degree
relatives; patients with prior chest radiation between the ages of 10 and 30;
those with certain syndromes associated with propensity for breast cancer; and
Patients with a lifetime risk for breast cancer of >20% to 25% as determined by risk models.

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Insufficient evidence was found to recommend for, or against, screening MRI for women at
intermediate risk, which included:
those with a lifetime risk for breast cancer of 15%to 20% defined by risk
models; prior diagnosis of atypia or lobular carcinoma in situ;
patients with dense breasts on mammography; or
Patients with a personal history of breast cancer.
The decision for these patients should be made on a case-by-case basis. Screening breast MRI is not
recommended in women with <15% lifetime risk of breast cancer.
Breast MRI may be helpful in certain situations in which there is an equivocal mammographic
abnormality and for 3-dimensional localization of a lesion seen on one view only. These situations
predominantly include asymmetries, architectural distortions, and equivocal changes in the
appearance of prior surgical or biopsy sites. It is generally accepted that the negative-predictive value
of MRI in the setting of suspicious and/or indeterminate mammographic or sonographic findings is
limited, at best 85%, which is not high enough to exclude the need for biopsy.
PET-MRI
It combines the advantages of MRI-superior soft tissue contrast, diffusion imaging and dynamic
contrast imaging with the quantitative physiological and metabolic data provided by PET.

OPEN MRI
Open MRI is a system where the machine bore is open on two or three sides unlike a closed system which
is a doughnut shaped the benefits of open MRI machines can include: Higher levels of patient comfort,
Reduced claustrophobia and patient-size concerns Greater ease when placing critical body parts directly
under the magnet. The difference also is of the magnetic strength, open MRI has a permanent magnet and
generally range from 0.3T to 0.7T, with some systems reaching 1.2T. Closed MRIs are “superconducting”
magnet and have strength of 1.5T to 3.0T. Think of T strength like the engine of a car. Imagine the open bore
MRI as a Honda city, for instance, and the closed MRI as a powerful sports car. In some situations, it’s
useful to have the roaring power of the Ferrari, but often, the Honda city gets you where you need to go.
KINEMATIC MRI
Kinematic MRI refers to imaging a joint through a range of motion to examine the interactions between the soft
tissue and osseous anatomy that comprise the joint. Kinematic MRI techniques are required because various
pathologic conditions are dependent on the specific position of the joint or in response to loading or stress.

NEWER ADVANCES IN MRI

Diffusion-weighted imaging (DWI)

Diffusion imaging is one of the magnetic resonance imaging (MRI) sequences providing qualitative as well
as quantitative information at a cellular level. It has been widely used for various applications in the central
nervous system .Diffusion is the constant and uninhibited random Brownian motion of water molecules.
Diffusion of water at the molecular level in biological tissues is modified and limited by interactions with cell
membranes and macromolecules. Magnetic resonance imaging (MRI) diffusion-weighted imaging (DWI)
uses the differences in the motion (diffusion) of water molecules in extracellular and intracellular fluid and
vascular fluids to produce image contrast, with no need for exogenous contrast materials. DWI has been
predominantly used in the brain in the evaluation of stroke and can help diagnose ischemic changes before
signal alterations of other pulse sequences and morphological abnormalities become apparent.
It has now an important role in abdominal imaging as any mass which shows diffusion restriction
means it has high cellularity.

MR –ELASTOGRAM

Magnetic resonance elastography is a technique that measures the mechanical properties (stiffness)
of soft tissues by introducing shear waves and imaging their propagation using MRI. Pathological
tissues are often stiffer than the surrounding normal tissue. For instance, malignant breast tumors are
much harder than healthy fibro-glandular tissue. This characteristic has been used by physicians for
screening and diagnosis of many diseases, through palpation. MRE calculates the mechanical
parameter as elicited by palpation, in a non-invasive and objective way.

It is currently being clinically used for the assessment of hepatic fibrosis since it is well known that
the liver stiffness increases with the progression of this disease. It is being investigated for the
diagnosis of diseases and also for studying the treatment efficacy.

MRI is an extremely versatile imaging modality. There are certain areas where it is now the imaging modality of
choice-neurological and musculoskeletal applications, prostate imaging, pelvic floor and pelvic malignancies. It is
now gaining ground in bowel and other abdominal applications. The major advantage being that there is no
radiation involved and hence can be used for frequent follow up examinations and in young patients.
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 APPROACH TO A SOLITARY THYROID NODULE
-Dr. Prof. Chintamani

Solitary thyroid nodule(STN) is defined as a palpable nodule in an otherwise normal(non-palpable)

gland. It should be appreciated that a normal thyroid gland is not palpable(fig.3.1).
STNs are found in approximately 4-9 % of patients (The detection rate, if ultrasound is used along with
clinical examination is higher i.e roughly around 22% and it has been reported that only 38% of
clinically solitary nodules are demonstrated to be solitary on high resolution ultrasound) [1-5].
May be malignant although most are due to benign conditions.Care is therefore necessary to exclude
malignancy and while planning treatment , an effort has also to be made to pick up patients at a higher
risk of developing thyroid cancer.
There is definite need to emphasize the importance of a trained, effective ,safe and well-informed
surgeon to perform these surgeries rather than taking this to be a run of the mill job as the surgery
may be associated with a lasting postoperative morbidity.

Classification:
Based on isotope scan [rarely used in the algorithm for the management of STN these days]:Most
patients with solitary thyroid nodules are euthyroid
Hot-autonomous toxic nodule-(5% nodules are hot with less than1% risk of maligancy)
Cold –Non-functioning nodule(80-85% nodules are cold on scintigraphy with14-22% of them ultimately
proving to be malignant)
Warm-may be a normally functioning nodule(10-15% are warm or indeterminate nodules, they harbour
malignancy more than the hot nodules10-36%)[6,7]

Based on FNAC or fine needle aspiration cytology for malignant potential (more commonly used in
the algorithm for the management of STN)[8,9,10].:
Benign(60-75%)[colloid nodules in 90% of cases and chronic inflammatory lesions like
Hashimoto`s thyroiditis, DeQuirvains thyroiditis in the other 10%].
Malignant(3.4-5%)
Insufficient(7-29.5%)
Suspicious(7.2%-30%)

Diagnostic approach to thyroid nodules:

I.Clinical assessment:
Presentation usually as an asymptomatic mass (incidental finding by the patient or the surgeon).

Factors increasing/predicting the risk of malignancy in a thyroid nodule

Previous head and neck
irradiation, Rapid growth,
Signs and symptoms of compression /invasion like dysphagia, dysphonia and
hemoptysis, Pain
Male sex
Extremes of ages( <20 or > 60years).
Family history of thyroid cancer or multiple endocrine neoplasia.
The appearance or enlargement of nodule while receiving thyroid suppression therapy is especially
troublesome. Nodules >4cm in diameter
Fixation to the skin and soft tissue indicating extraglandular spread
Firm or hard nodule(even within a diffusely enlarged thyroid gland as 14-20% of thyroid cancers may have
diffuse or focal thyroiditis)
Cervical lymphadenopathy along with a thyroid nodule
Presence of vocal cord paralysis on laryngoscopy

II.Laboratory Investigations:
Have limited role as routine investigatios although form a part of mandatory evaluation of the functional
status of thyroid.None is a sensitive predictor of malignancy except calcitonin for medullary carcinoma.
Functional status of thyroid is evaluated routinely during the assessment of a STN although most
patients with thyroid nodules are euthyroid.The high sensitivity thyrotropin assay is perhaps the most
useful test to perform (a reduced thyrotropin level may indicate hyperthyroidism such as in an
autonomous functioning gland or thyrotoxicosis and an elevated thyrotropin level indicates
hypothyroidism or thyroiditis, in both these situations the gland may be enlarged or nodular).
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Thyroglobulin level may be obtained (one of the major limitations of serum thyroglobulin assay is
presence of thyroglobulin antibodies that may be present in 15-30% of patients with well diffrentiated
thyroid cancer and in nearly 10% of normal subjects)
Preoperative assay has no diagnostic role in malignancy and the utility is for follow up of cancer
patients after thyroidectomies.
Calcitonin level should be done in high-risk patients such as patients with familial medullary thyroid
carcinoma or multiple endocrine neoplasia.

N.B:Recent studies suggest and recommend a routine use of calcitonin assay, followed by pentagastrin –
stimulating test if an abnormal level of calcitonin is found in a patient with nodular diseases.This is basically
because a)the incidence of sporadic medullary thyroid cancer is higher than thought earlier.b)sporadic medullary
thyroid cancer is difficult to diagnose on FNA because of its varied morphology.Unlike familial medullary thyroid
carcinoma which can be diagnosed earlier with family history and gene testing, sporadic variety presents later
with lymph node metastasis and is more aggressive.Thus a routine calcitonin level may show an aggressive
tumour at an earlier stage (microscopic tumous without nodal metastasis).

Imaging modalities
Radio isotope imaging
Rarely used these daysas scintigraphy offers no additional diagnostic help but is a powerful adjunct
to other diagnostic modalities like FNA and USG. When grouping the “cold” and “warm” nodules
together the sensitivity of scintigraphic scans for cancer diagnosis is 89% to 93% but specificity is 5%
with a positive predictive value of only 10%[6].The limited indications for scintigraphy in solitary
thyroid nodules are: Identification of a functional thyroid nodule when initial thyrotropin is dercreased.
If an FNA is reported as “follicular neoplasm” or suspicious, finding of a hot nodule might decrease
the suspicion of a malignancy (up to10% of carcinomas are functional and therefore “hot”).

Detecting neck metastasis.

Thallium-201 scan a useful adjunct to FNA has been recommended in some studies to differentiate between
benign and malignant nodules especially if FNA is inconclusive.The risks of malignancy for low- uptake,
intermediate –uptake and high- uptake lesions have been reported to be 0%,6% and 55% respectively.[2]

b) CT and MRI scan:

CT has no definite role in the initial work up of a solitary thyroid nodule except for detection of thyroid
tissue in the retroclavicular/ mediastinal regions and also for cervical metastasis.
Non contrast CT scan is advised on account of inherent high iodine content in thyroid and the iodine
based contrast might delay any nuclear scintigraphy for 4-8 weeks because of saturation of iodine
agents in the cellular components of thyroid gland.
MRI also plays a minor role in detecting the involvement of soft tissue, extraglandular involvement
and involvement of carotids. The advantage of MRI over CT scan is the use of contrast (gadolinium)
which does not interefere with nuclear scintigraphy.

c) Ultrasound(USG)
Using high frequency transducers(7-13 MHz) modern ultrasound is a very important imaging
technique for the evaluation of solitary thyroid nodule.USG can detect nodule as small as 3-4mm, if
solid and cystic nodules of up to 2mm in diameter.
It is a safe, non invasive, non radioactive test and is recommended for:
Non palpable or difficult to palpate nodules for US-guided FNA
Follow-up imaging of solitary nodules that are managed medically or by
observation As an adjunct to repeat FNA when the FNA is non-diagnostic.
Ultrasound has been found to change the management of STNs that were referred based on the findings of
multiple nodules, no nodules were actually identified and may detect very small nodules (<1cm).Based on
this published series,it has been recommended that USG should be routinely considered in the evaluation
of a solitary thyroid nodule[2].However,cost and subjectivity restrict its routine use.Nodules may be cystic
or solid. Purely cystic nodules are rare and partially cystic nodules account for 20% of the nodules.Cystic
lesions are reported to carry a lower risk of malignancy(0.5-3%) and pure cystic nodules may be aspirated
for cytology.Purely solid nodules have a higher risk of malignancy(~10%)[2].
Benign nodules such as adenomas are surrounded by a capsule that shows as a halo, absence of
which is suggestive of extracapsular extension and malignancy.
Calcium deposits can be fine punctate findings in papillary cancer corresponding with psammoma
bodies histologically. Routine use of USG is probaboly not recommended at present due to cost,
subjective interpretation and the existence of alternative diagnostic tools like FNAC.

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 USG features of malignancy in a STN
Absent “halo” sign
Solid or hypo-echogenecity
Heterogenous echo
structure Irregular margins
Fine calcifications
Extraglandular extension
N.B: The best use of USG as a diagnostic modality is in combination with FNAC if
the aspirate is inconclusive.
IV. Fine needle aspiration cytology (FNAC)
The main goal of FNAC is to accurately diagnose and predict which nodule is cancerous.In various
studies sensitivity of 65-100% and specificity of 70-100% and over all accuracy of 92%-95% has been
reported .In most series false positive rate of approximately 0.8% to 9% and false negative rate of 0%
to16% has been reported[9-14].
It is now considered the “gold standard” in the diagnosis of STN ahead of other diagnostic modalities
like Isotope scans etc.for the following reasons.
FNAC as the first diagnostic modality has significantly contributed towards a decrease in the number
of thyroidectomies performed and increase in the yield of malignancies in the excised glands[8].
FNAC is a safe and quick procedure without any radiational exposure.
FNA decreases the cost of care by approximately 25% by eliminating unnecessary surgeries and limiting the
use of frozen section intra-operatively.The cost has been found to reduce by 50% in some studies[9].

Limitations of FNAC:
Subject to operator`s experience
Dependent on the placement of the
needle Sensitivity of finger tips
Amount of suction applied
Negative FNAC does not absolutely rule out the pathology
N.B:Recently a technique of needle biopsy without suction has been advocated to
reduce traumatic blood aspiration and has been found useful in smaller nodules.This
technique uses the needle for cutting and the capillary pressure of tissue for sampling.
The ancillary tests that improve the accuracy of FNAC include immunohistochemistry, ploidy studies,
molecular markers and Reverse Transcription-Polymerase chain reaction(RT-PCR) to detect
thyroglobulin mRNA and thyrotropin receptor mRNA[5,9].

Causes of suspicious FNAC reports

Follicular adenoma (difficult to differentiate from well differentiated follicular
carcinoma) Hurthle cell carcinoma
Follicular variant of papillary carcinoma
Low- grade papillary carcinoma
Hyalinizing trabecular adenoma
Hashimoto`s thyroiditis with metaplasia
Any cancer with suboptimal sampling
Adenomatous goiter with microfollicular structure predominance.

Complications from FNAC

Pain
Hematoma
Entry in to trachea
Transient thyroid swelling
Cystic degeneration
Transient bradycardia
Transient vocal cord palsy
Formation of calcification
Necrosis of nodule
Capsular psedo-
invasion Fibrosis
Transient thyrotoxicosis
Elevation of thyroglobulin level

With a good yield and if the cytopathologist is competent the sensitivity of FNAC is close to 90% .The
yield and therefore the sensitivity can be improved by performing, what is becoming popular now,
ultrasound guided FNAC (USFNA)[15,16].
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Simple colloid nodules constitute approximately 65-70% while nearly 20% are possible follicular
neoplasms or indeterminate nodules and 5-10% are found to be malignant.
False-positive diagnoses with FNAC are rare, however false negative diagnosis may be a problem
besides the investigation being operator dependent.
If the specimen obtained is inadequate, FNAC may have to be repeated on two occasions . In case of
equivocal results ,the benefit of doubt should rest with the patient and it may be necessary to perform
hemithyroidectomy in such cases.
With small, non-palpable masses, FNA should be performed under ultrasound guidanceboth for better
yield and a more representative sample.
The algorithm for the diagnosis of a thyroid nodule in most centers is now based on FNACinstead of
isotope scintigraphy and ultrasonography as initial steps(Fig.3.2).

Fig. 3.2: algorithm of an approach to an

STN Management of the solitary thyroid nodule

Surgery:
If the FNA is suggestive of malignancy, surgery is obviously required. Some studies have
recommended the clinical factors ahead of FNA and inspite of FNA for considering surgery in STN
[15]. Brooke et al prospectively studied 564 patients between 1996 and 1999 and concluded that the
preoperative FNA had no direct impact on selection of surgical procedure, the majority of thyroid
operations were planned and performed based on known prognostic and intra-operative factors[15].

Management algorithm according to FNAC results:

FNA suggestive of a benign nodule: needs to be followed up closely with or without USG.Repeat FNA
after six months in those with high risk factors reduce the false negativity rate by 50%.
Thyroid suppressive therapy that was once used as a short term diagnostic tool is now obsolete and
thus not recommended.
Thyroid suppressive therapy has been found to be effective in only 10-20% benign nodules, these are
better follwed up without suppressive therapy [2,17]
FNA suggestive of malignant nodules-the management is straightforward because of the predictive
value of FNA in malignant nodules is clos to 100% with a specificity also close to 100%. Surgical
excision is therefore warranted.
FNA indicating a suspicious group: which includes Follicular neoplasm or Hurthle cell neoplasm is
proaboly the limiting factor of FNA. The FNA results can account for up to30% of FNA`s in some
series, the overall malignancy rate of these lesions is 10%-20%[2,9] and even higher[10,12].These
numbers strongly suggest need for surgical management.
FNA suugestive of -- non diagnostic or “insuffucient” for diagnosis. When this result is obtained, a
repeat FNA is performed possibly with ultrasound guidance to increase the yield.

Extent of surgery:
Except for lesion confined to isthmus, least extensive procedure recommened is hemithyroidectomy
i.e lobectomy with isthumectomy.[2,17]
Limited to isthmus-simple excision of the nodule can be done leaving the two lobes intact although the author
would like to perform the hemithyroidectomy if there is a likelihood of lesion extending towards either lobe.
If there was a doubt of malignancy in the pre-operative period and maliganancy still needs to be ruled
out, the specimen is examined by frozen section to determine the need for further surgery at the same
setting. An exception to the practice is presence of follicular neoplasm that falls in to the suspicious
category of FNA results where a frozen section analysis is unlikely to provide further information.
Need for TT in presence of malignancy is controversial [18]. Although some investigators advocate TT as
the procedure of choice for patients withWDTC, others reserveTT or NTT for the high risk group of patients.
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High risk group includes:
>45years <20years
Lesions>4cm
Tumours with extraglandular extension
Regional or distant metastasis
Histologically more aggressive tumours
There is consensus that TT should be performed for high risk groups.Some recommed the same
approach in low risk group, the advantages of TT should be weighed against the risks of RLN
paralysis, hypopararhyoidism which are increased at the hands of inexperienced operator.

Clinical factors warranting surgery irrespective of FNA findings:

Age (<20years or
>45years) Sex (male sex)
Nodules occuring in patients with Grave`s disease or Hashimoto`s
thyroiditis. Previous radiation to cervical region
Strong family history of thyroid
cancer Pain
Compressive/infiltrative /invasive
features Cervical metastasis
Large nodule(>4cm in
diameter) Rapid growth
Growth despite thyroid suppression therapy

Surgical approach to STN:

Guiding principles:
Surgery is the treatment of choice in patients with malignancy although the extent of optimum surgery
is controversial.Follicular neoplasms on FNAC should also undergo surgery although around 90 % of
these nodules are benign. Generally it is not possible to differentiate between follicular carcinoma and
adenoma by FNAC, as one has to look for capsular and/or vascular invasion for which histopathology
of the specimen (after surgery) is more reliable.
In case of a colloid nodule, one may or may not operate depending upon the protocol of the unit
although the author would like to err on the side of operating on cases with an element of doubt [when
in doubt take it out being the dictum].
The author routinely performs and recommends surgery in cases of colloid nodules with tracheal
compression or substrenal extension or if the patient desires it on cosmetic grounds.

Irradiation and surgery for thyorid:

The surgical approach and overall management of solitary nodules would also differ for a high risk
group i.e those patients who have been exposed to low dose radiations in the child hood, from the
rest. The high dose radiations in the childhood are no longer thought to be providing protection
against thyroid cancer contrary to the earlier belief.

Management of STN in Non-irradiated Patients

Any STN suspected of being a carcinoma should be completely removed, along with surrounding
tissue i.e atleast hemithyroidectomy (lobectomy with isthmectomy) should be done. [The minimum
surgery in thyroid disorders as practiced and recommended by the author is “hemithyroidectomy”].
In an ideal scenario a frozen section may be performed intra-operatively in order to proceed with any
additional surgical manouvere in the same sitting.
If it comes out to be a colloid nodule on frozen section, hemithyroidectomy is generally considered
optimum. If it is a follicular neoplasm, treatment becomes more controversial. Frozen section may not
completely be relied upon in this situation due to its limitation in differentiating a follicular adenoma from a
carcinoma, or a benign Hurthle cell tumor from Hurthle cell carcinoma.This is because a very careful
assessment of capsular and vascular invasion is required which may be difficult to achieve with frozen
section.In this situation and /or when there is no frozen section facility available the minimum surgery that
the author would perform and recommend is hemithyroidectomy. The decision in these patients regarding
further surgery or radioactive iodine is taken based on the report by the histopathologist.This may actually
amount to doing nothing more or proceeding with completion thyroidectomy in cases with a
histopathological diagnosis or strong suspicion of malignancy. Radioactive iodine ablative therapy has also
been recommended instead of completion thyroidectomy, by some authors [18].
Some surgeons like to treat the benign STN`s with thyroxine replacement therapy alone[17]. It is
author`s practice to perform hemi-thyroidectomy in these cases and it has often been observed that
the final histolopathological diagnosis in majority of these cases turned out to be a malignancy.

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Management of STN in Irradiated Patients;
The risk of malignancy in this group of patients (i.e those exposed to low dose external beam radiations
during infancy or childhood) being higher, influences the management strategies and most surgeons would
err on the side of doing more rather than less in these cases. This would amount to performing total
thyroidectomy (TT) or near total thyroidectomy (NTT) with or without biopsy from the jugular nodes.
In the case of a multinodular goiter (an STN detected intra-operatively to be multinodular) even if the
dominant nodule on frozen section comes out to be benign , TT or NTT is recommendedas there is a
strong possibility of coexistence of benign and malignant nodules in a large number of these cases.
Another reason for performing TT or NTT in this group is a high incidence of bilaterality of the disease
and a high possibilty of papillary carcinoma (approximately 35% of these cases).
In addition, those patients in this group who have received high dose of radiations (i.e more than 2000 rads) to
their thyroid bed e.g those treated with upper mantle irradiation for Hodgkin`s disease, are at a greater risk for the
development of thyroid carcinoma and should be kept under close surveillance. High dose radiations are no
longer believed to be providing any kind of protection against thyroid cancers as was earlier thought .

N.B: High dose radiations were earlier thought to be protective against thyroid carcinoma , it is no
longer thought so and on the contrary, a higher risk of papillary cancer has been observed,
particularly in patients with Hodgkin`s disease.

References:
Castro MR,Gharib H.Thyroid nodules and cancer, when to wait and watch, when to refer.Postgrad Med 2000:107(1):113-24
Miller FR ,Otto RA Disorders of the thyroid .Otolaryngol Clin N Am ;36: 2003. 1-7
Vander JB.Gaston EA,Dawber TR.The significance of non toxic thyroid nodules: final report of a 15 year study of the
incidence of thyroid malignancy. Ann Intern Med 1968.
Barguera B, Gharib H. Thyroid incidentalomas: prevalence, diagnosis,significance and management. Endocrinol Metab Clin
North Am 2000;29(1): 187-203
Torrens JI, Burch HB.Serum thyroglobulin measurement: utility in clinical practice. Endocrinol Metab Clin North
Am2001:30(2):429-467.
Cases JA, Surks MI.The changing role of scintigraphy in the evaluation of thyroid nodules.Semin Nucl Med 2000;30(2):81-87
Sabel MS, Staren ED. Gianakis LM et al.Effectiveness of the thyroid scan in evaluation of the solitary thyroid nodule.Am
Surg 1997;63(7):660-667.
Sidawi MK, Del Vecchio DM, Knoll SM.Fine needle aspiration of thyroid nodules : correlation between cytology and
histology and evaluation of discrepant cases.Cancer 1997;81:253-259
Belfiore A,La Rosa GL. Fine needle aspiration biopsy of the thyroid.Endocrinol Metab Clin North Am2001;30:361-400.
AmrikachiM,Ramzy I, Rubenfield S et al. Accuracy of fine needle aspiration of thyroid: a review of 6,226 cases and
correlation with surgical or clinical outcome. Arch Pathol Lab Med 2001;125:484-488
Chehade JM, Silverberg AB, Kim J et al.Role of repeated fine needle aspiration of thyroid nodules with benign cytologic
features. Endocr Pract 2001;7:237-243
Boyd LA,Earnhardt RC, Dunn JT et al.Pre-operative evaluation and predictive value of the fine needle aspiration cytology
and frozen section of thyroid nodules. J Am Coll Surg 1998;187:494-502.
Schmidt T,Riggs MW, Speights VO. Significance of non-diagnostic fine needle aspiration of the thyroid.South Med J
1997;90:1183-1186.
SubelMS,StarenED,Gianakakis LM et al. Use of fine needle aspiration biopsy and frozen section in the management of
solitary thyroid nodule.Surgery 1997;122:1021-1027
BrooksAD, Sinha AR, DuMornay W et al.Role of fine needle aspiration biopsy and frozen section analysis in the surgical
management of thyroid tumours. Ann Surg Oncol 2001;8:92-100..
Carmeci C,Jeffery RB,Mc Dougall IR et al.Ultrasound guided fine needle aspiration biopsy of thyroid masses.Thyroid 1998;8:283
Gharib H,Mazzaferri EL.Thyroxin suppressive therapy in patients with nodular thyroid disease.Ann Intern Med 1998;128:386-394
Sinha AR. Controversies in the management of thyroid nodule. Laryngoscope 2000;110:183-193.

PHEOCHROMOCYTOMA
-Dr. Ajay K Khanna

Pheochromocytomas are neuroendocrine neoplasias derived from the chromaffin cells of the adrenal
medulla which results in unregulated episodic over secretion of catecholamines. . It takes its name from the
brown granules (pheo) which are produced by the oxidation of the catecholamines with the chromic acid.
The term is from Greek phaios "dark", chroma "color", kytos "cell", -oma "tumor". In 1886, Felix Fränkel
made the first description of a patient with pheochromocytoma. The term "pheochromocytoma" was first
coined by Ludwig Pick, a pathologist, in 1912. In 1926, César Roux (in Switzerland) and Charles Horace
Mayo (in the U.S.A.) were the first surgeons to successfully remove pheochromocytomas.
80 to 90% of these tumors are located in one of the adrenal glands whereas 10-15% arise in Extra
adrenal chromaffin tissue like paravertebral ganglia, posterior mediastinum, organ of Zukerkandl and
urinary bladder. This tumor secretes noradrenaline or other catecholamines. It may also secrete
Calcitonin, ACTH, Vaso active intestinal polypeptide (VIP) and PTH related polypeptide.
The adrenal medulla has two cell populations that synthesize catecholamines and other proteins
through intracrine, endocrine, and paracrine mechanisms.
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The most well-known of these is the interaction of the nicotinic receptor bonded to G proteins in the membrane.
This bond develops a sequence of biochemical and physical processes to activate the enzymes: tyrosine
hydroxylase, tyrosine → DOPA, decarboxylase of the L aromatic amino acids → dopamine, β hydroxylase
dopamine → norepinephrine, phenylethanolamine-Nmethyltrasferase (induced by cortisol) → epinephrine, COMT
(catechol-O-methyl transferase) → normetanephrine and metanephrinemao → mopgal (3-methoxy-4-hydroxy-
phenyl glycoldheyole).Pacap (pituitary adenylate cyclase-activating polypeptide) acts like a neurotransmitter that
regulates the release of catecholamines and can implement trophic and apoptotic effects. These could influence
the progress and differentiation of neoplasic cells. NPY (Y neuropeptide) is a peptide with a 36 amino acid chain
present in the normal adrenal medulla and in the pheochromocytoma that regulates locally the secretion of
catecholamines. Cortisol activates COMT enzyme, at the intra-adrenal portal between cortex and medulla, to
synthesize and to secret catecholamines. The larger concentrated biosynthetized catecholamine is epinephrine
with 80% of all the catecholamines secreted by the medulla in normal conditions. Norepinephrine is the
catecholamine mainly synthetized in the sympathetic ganglia.

Clinical Presentation :
Pheochromocytomas are, fortunately, quite rare, and most of them are benign.The peak incidence is
between the third and the fifth decades of life. Pheochromocytomas are present in only about 0.2% of
all people with high blood pressure.
The signs and symptoms of a pheochromocytoma are those of sympathetic nervous system hyperactivity. Due to
its clinical heterogeneity, this tumor has been called the ‘great mimic’. It has the classic triad: episodic headache,
generalized diaphoresis and tachycardia. About 50% of them have paroxysmal hypertension and 40% sustained
systemic arterial hypertension, 5 to 15% are normotensive. Patients can present with other symptoms:
papilledema, dyspnea, pallor, general weakness, panic spells, orthostatic hypotension, blurred
vision, papilledema, weight loss, polyuria, polydipsia, constipation, hyperglycemia, leukocytosis,
thrombocytosis, erythrocytosis, psychiatric disorders, cardiomyopathy due to excess
catecholamines, lung acute edema, arrhythmia, anesthesia induced hypertension. Rarely patients may
also present with diarrhea if the secreting agent in the tumor is vasoactive intestinal peptide (VIP).
Pheochromocytoma should be suspected in patients who have one or more of the following: Resistant
hypertension, refractory hypertension. Hypotension crisis, hyper adrenergic spells (episodes,
palpitations, diaphoresis, headache, tremor, or pallor), Unfavorable cardiovascular responses to
anesthesia, tricyclic antidepressants, phenothiazine, histamine etc.
On physical examination the most important finding is elevated blood pressure. Hypertension is
transient in 50% of the cases and may be persistent finding. Hypertension may be severe enough to
cause encephalopathy. Sinus tachycardia is the commonest form of finding among arrhythmias
associated with pheochromocytoma but however, ventricular tachycardia has also been observed in
some patients which may or may not be accompanied with dilated cardiomyopathy, Other physical
findings could be Neurofibroma ,Café au let spots , Diabetes, Goiter, Tachycardia and
tachyarrhythmias , Retinopathy, Fever , Cardiomyopathy , Pulmonary edema.

10% rule: About 10% of these tumors are malignant; 10% are present in children; 10% are bilateral;
10% are extra-adrenal; 10% are familial ones. (Hereditary pheochromocytoma), 10% are diagnosed
after an event of stroke, 10% are not associated with hypertension, 10% multiple, 10% calcified.
Etiology and associated syndromes Pheochromocytoma which occur in the hereditary form are
associated most commonly with following syndromes a) MEN 2A. b) MEN 2B. c) Von Recklinghausan
disease or Neurofibroma. Both are genetic syndromes that run in families and are transmitted from
parent to child in an autosomal dominant manner.

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Mutations of the genes VHL, RET, NF1 (Gene 17 Neurofibromatosis type 1), SDHB and SDHD are all
known to cause familial pheochromocytoma, therefore this disease may be accompanied by Von
Hippel–Lindau disease, neurofibromatosis, or familial paraganglioma depending on the mutation.
Extra-adrenal pheochromocytomas usually weigh 20 to 40 g and are <5 cm in diameter. Most are
located within the abdomen in association with the celiac, superior mesenteric, and inferior
mesenteric ganglia and the organ of Zuckerkandl. Approximately 10% are in the thorax, 1% are within
the urinary bladder, and less than 3% are in the neck, usually in association with the sympathetic
ganglia or the extracranial branches of the ninth cranial nerves. The following parameters may
distinguish between benign and malignant cases by Necrosis, Haemorrhage, High Ki 67, Size of
tumor, capsular invasion, vascular invasion, nuclear DNA ploidy, Increased Neuron Specific Enolase.

Clinically Silent Pheochromocytoma

Approximately 5% of adrenal incidentalomas have proved to be pheochromocytomas. In one study, 19
of 33 adrenal pheochromocytomas (58%) were detected initially as incidental adrenal masses, and
only 10 of the 19 patients had hypertension. However, even clinically silent pheochromocytomas can
be lethal The differential diagnoses of pheochromocytoma include:
Anxiety disorders
Paragangliomas
Von Hippel–Lindau Disease
Essential hypertension
Hyperthyroidism
Insulinoma
Mercury poisoning
Paroxysmal supraventricular tachycardia
Renovascular hypertension
Carcinoid

Diagnosis:
The most important biochemical tests for diagnosing pheochromocytomas are: free plasma metanephrines, free
plasma normetanephrine and metanephrine, 24 hour urinary excretion of catecholamines and their metabolites
(metanephrine, Vanillymandelic acid). Plasma metanephrine testing has 96% sensitivity but85% specificity.
24-hour urinary collection for catecholamines and metanephrines has 87.5% sensitivity and 99.7%
specificity. Plasma metanephrine testing is usually done in patients at high risk (i.e, those with
predisposing genetic syndromes or a family or personal history of pheochromocytoma) while 24-hour
urinary catecholamines and metanephrines are done in patients at lower risk.
The diagnosis can be established by measuring catecholamines and metanephrines in plasma (blood)
or through a 24-hour urine collection. Care should be taken to rule out other causes of adrenergic
(adrenalin-like) excess like hypoglycemia, stress, exercise, and drugs affecting the catecholamines
likestimulants,methyldopa,dopamineagonists, or ganglion blocking antihypertensives. Various
foodstuffs (e.g. coffee, tea, bananas, chocolate, cocoa, citrus fruits, and vanilla) can also affect the
levels of urinary metanephrine and VMA (vanillylmandelicacid).
Additional studies to rule out a familial syndrome in patients with confirmed pheochromocytoma
include the following:Serum intact parathyroid hormone level and a simultaneous serum calcium level
to rule out primary hyperparathyroidism (which occurs in MEN 2A), Screening for mutations in the ret
proto-oncogene (which give rise to MEN 2A and 2B), Genetic testing for mutations causing the MEN
2A and 2B syndromes and ophthalmic examination to rule out retinal angiomas (VHL disease)
Sometimes the clonidine stimulation is done. Clonidine stimulates the α2 adrenergic receptors at the
brain and prejunctional neuronal levels, thus if there is a decrease of elevated normetanephrine to
normal concentrations after the clonidine test, indicates that the sympathetic activation is its source,
and a lack of decrease in plasma free normetanephrine< 40% and the persistence of plasma free
metaneprhine> 0.61 nmol/L three hours after administering clonidine indicate the presence of
pheochromocytoma.Chromogranin A is elevated in case of pheochromocytoma.
CT or MRI scan should be used for detection of adrenal masses. MRI has 100% sensitivity in detecting
adrenal pheochromocytoma tumors. Scintigraphy is carried out in cases where CT and MRI scanning
is unable to localize the tumor. PET scan is another technique which can efficiently localize the tumor
in pheochromocytoma.
CT scanning is the imaging test of choice and identifies 90-95% of pheochromocytoma larger at 1 cm.
MR scan shows characteristic high intensity in T2 weighted image . MIBG (I131 Meta
Iodbenzylguanidine) provides a functional and anatomic test of hyperfunctioningchromaffian tissue.

Management
Perioperative Risk Assessment and Preoperative Planning
Treatment for pheochromocytoma is surgical resection. Laparoscopic tumor removal is indicated in
localized, small tumors with easy approach.
135
Open laparotomy is indicated in conditions where laparoscopic approach is not feasible or the tumor is
larger in size. In most of the cases symptoms wears off after surgery however, special attention should be
paid before handling the tumor in avoiding hypotension due to abrupt removal of catecholamines from the
blood after surgery. Therefore, patient is advised adequate hydration and salt intake.
Pheochromocytomas represent significant management challenges to the anesthesiologist. From a
hemodynamic perspective, few other clinical situations present a more complex and life-threatening
situation - particularly when undiagnosed. The latter situation may precipitate a hypertensive crisis,
which can be life-threatening, with 80% mortality. Preoperative evaluation of these patients is key to
successful perioperative management. Roizen et al. in 1982 proposed a set of criteria (now called the
Roizen criteria) to objectively gauge the efficacy of adequate preoperative alpha blockade, and they
include: 1. No in-hospital blood pressure >160/90 mmHg for 24 h prior to surgery; 2. No orthostatic
hypotension with blood pressure <80/45 mmHg; 3. No ST or T wave changes for 1-week prior to
surgery; 4. No more than 5 premature ventricular contractions per minute.
Patients with pheochromocytoma are at significant risk for major adverse cardiac complications in the
perioperative period. Successful management requires careful preoperative optimization, meticulous
intraoperative planning, and hemodynamic management. All patients need to be monitored vigilantly
in the postoperative period given the high-risk of complications.
Patient with pheochromocytoma and hypertension should be managed towards control of blood
pressure in order to avoid dire consequences. Beta blockers are only indicated after alpha blockade
has been effectively introduced for at least 2 days. Only then beta blockers should be initiated which
otherwise would have lead to unopposed vasoconstriction and hypertensive crisis.
Alpha adrenergic blocker Phenoxybenzamine 10 mgm orally twice a day is initiated and increased to
20-40 mgm orally twice a day. Beta adrenergic blockade (Propranolol) may be added if tachycardia or
arrhythmia develops but only after alpha adregeric blockade.
Intraoperative labile hypertension can be prevented by minimal manipulation of tumor but can be
controlled by intravenous Sodium Nitroprusside (0.5-10 ugm /kg/min) or phentolamine (5 mgm).

Preoperative medical stabilization is provided as follows:

Start alpha blockade with phenoxybenzamine 7-10 days preoperatively
Provide volume expansion with isotonic sodium chloride solution
Encourage liberal salt intake
Initiate a beta blocker only after adequate alpha blockade, to avoid precipitating a hypertensive
crisis from unopposed alpha stimulation
Administer the last doses of oral alpha and beta blockers on the morning of surgery

The Endocrine Society, the American Association for Clinical Chemistry, and the European Society of
Endocrinology have released clinical practice guidelines for the diagnosis and management of
pheochromocytoma and paraganglioma (jointly referred to as PPGL).
Preoperative blockade of hormonally functional PPGL to prevent cardiovascular complications is
recommended, along with preoperative medical treatment to normalize blood pressure and heart rate
and a high-sodium diet with fluid intake to prevent severe hypotension after removal of the tumor.
Blood pressure, heart rate, and glucose levels should be monitored immediately after surgery.
Minimally invasive (eg, laparoscopic) adrenalectomy should be performed for most adrenal
pheochromocytomas, with open resection reserved for very large or invasive pheochromocytomas; open
resection is suggested for paragangliomas, but laparoscopic resection is an option for smaller tumors;
partial adrenalectomy is also an option for certain patients.
Surgical resection of the tumor is the treatment of choice for pheochromocytoma and usually results
in cure of the hypertension. Careful preoperative management is required to control blood pressure,
correct fluid volume, and prevent intraoperative hypertensive crises. Independent risk factors for a
hypertensive attack during adrenalectomy for pheochromocytoma include a large tumor size and
preoperative elevation of the urinary epinephrine level.
Although there is no consensus regarding the preferred drugs for preoperative blood pressure control,
alpha blockers, beta blockers, calcium channel blockers, and angiotensin receptor blockers have all been
used. Start alpha blockade with phenoxybenzamine 10-14 days preoperatively to allow for expansion of
blood volume. The patient should undergo volume expansion with isotonic sodium chloride solution.
Encourage liberal salt intake.Initiate a beta blocker only after adequate alpha blockade (usually, 2 days). If
beta blockade is started prematurely, unopposed alpha stimulation could precipitate a hypertensive crisis.
Administer the last doses of oral alpha and beta blockers on the morning of surgery.
No distinction is found in hypertensive episodes during surgery for pheochromocytoma associated with multiple
endocrine neoplasia type 2 (MEN 2) and non-MEN–associated pheochromocytoma. Therefore, pretreatment using
alpha and beta-adrenergic blockers remains a standard of care in both groups of patients.
Test plasma free metanephrines 2 weeks postoperatively. If results are within the reference range,
resection is deemed complete; in such cases, patient survival approaches age-matched controls. In
addition, ensure resolution of the hypertension and any associated complications.

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For surgical follow-up, obtain plasma metanephrine levels yearly for 10 years. Ensure that blood
pressure is under control. In patients with an underlying genetic mutation, lifelong follow-up is
mandatory. Pheochromocytoma in Pregnancy
If pheochromocytoma is found during pregnancy, initiate alpha-adrenergic blockade (with phenoxybenzamine) as
soon as the diagnosis is confirmed. Remove the tumor by laparoscopic adrenalectomy as soon as possible during
the first 2 trimesters, after proper preparation. Pregnancy need not be terminated. Spontaneous abortion is very
likely, however. During the third trimester, the patient should be managed medically until fetal lung maturity is
confirmed. Cesarean delivery is preferred, as mortality may be higher with vaginal delivery. The tumor may be
removed during the same session as the cesarean section, or it can be removed post partum.
Prognosis
Patient left untreated or with malignancy has poor prognosis. Malignant pheochromocytomas have 5 year
expected survival rate of almost 50%. In benign conditions, 5 years survival is up to 95%. There is increased
life-time risk of secondary cancers (relative risk 3.63), with a slightly increased mortality risk (1.21)

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Burnichon N, Cascon A, Schiavi F, Morales NP, Comino-Mendez I, et al. MAX mutations cause hereditary and sporadic
pheochromocytoma and paraganglioma. Clin Cancer Res. 2012 May 15. 18(10):2828-37.
Chen H, Sippel RS, O'Dorisio MS, Vinik AI, Lloyd RV, Pacak K. The North American Neuroendocrine Tumor Society
consensus guideline for the diagnosis and management of neuroendocrine tumors: pheochromocytoma,
paraganglioma, and medullary thyroid cancer. Pancreas. 2010 Aug. 39(6):775-83.
Därr R, Lenders JWM, Hofbauer LC, Naumann B, Bornstein SR, Eisenhofer G. Pheochromocytoma: Update on Disease
Management. TherAdv in Endo and Metab. 2012;3(1):11-26.
de Jong WH, Eisenhofer G, Post WJ, Muskiet FA, de Vries EG, Kema IP. Dietary influences on plasma and urinary metanephrines:
implications for diagnosis of catecholamine-producing tumors. J ClinEndocrinolMetab. 2009 Aug. 94(8):2841-9.
Eisenhofer G, Pacak K, Huynh TT, Qin N, Bratslavsky G, Linehan WM, et al. Catecholamine metabolomic and secretory
phenotypes in phaeochromocytoma. EndocrRelat Cancer. 2011 Feb. 18(1):97-111.
Elenkova A, Matrozova J, Zacharieva S, Kirilov G, Kalinov K. Adiponectin - A possible factor in the pathogenesis of
carbohydrate metabolism disturbances in patients with pheochromocytoma. Cytokine. 2010 Jun. 50(3):306-10.
Eisenhofer G, Goldstein DS, Walther MM, Friberg P, Lenders JW, Keiser HR, et al. Biochemical diagnosis of pheochromocytoma:
how to distinguish true- from false-positive test results. J ClinEndocrinolMetab. 2003 Jun. 88(6):2656-66.
Ferreira VM, Marcelino M, Piechnik SK, et al. Pheochromocytoma Is Characterized by Catecholamine-Mediated Myocarditis, Focal
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Fig. 1. CECT scan shows 4X3X3 cm size, Fig. 2. Intraoperative picture of Fig.3 Cut open specimen
well defined intensly heterogenous Pheochromocytoma of Pheochromocytoma
enhancing lobulated hypodense mass in
relation to right adrenal gland

NEUROENDOCRINE TUMORS OF PANCREAS

- Dr. Sundeep Singh Saluja, Ashsish Sachan

INTRODUCTION
Pancreatic neuroendocrine tumors (PNETs) are rare tumors and account for 1 to 4 % of all clinically
apparent pancreatic neoplasms1. Most PNETs are sporadic but about 10% are part of inherited disorders
such as multiple endocrine neoplasia type 1, Von Hippel-Lindau syndrome, neurofibromatosis and tuberous
sclerosis2,3. PNETs seem to arise from the islet cells of the pancreas and may or may not secrete
functionally active hormones and can therefore be classified as functional or non-functional tumors.
Functional tumors are usually detected early due to the symptoms caused by hormone production. Recent
studies suggest that most PNETs are non-functional and therefore are diagnosed either incidentally or late
due to non-specific symptoms caused by the local or distant tumor mass.

CLINICAL PRESENTATION AND CLASSIFICATION

PNETs are classified as two general categories, functional and nonfunctional, based on whether the
patients present a clinical syndrome caused by the hyper secreted hormones. Patients with functional
pNETs were diagnosed earlier than patients with nonfunctional pNETs (mean age of presentation 55
vs. 59 years) due to the different specific hormonal syndromes including gastrin, insulin, glucagon,
somatostatin, vasoactive intestinal polypetide (VIP), etc. (Table 1).

Table 1: WHO classification of neuroendocrine tumors 2010: Functional classification

Among the functional tumors, Insulinomas are the most common pNETs type, followed in decreasing
order by gastrinomas, glucagonomas, VIPomas, somatostatinomas, and other rare types5. For the
nonfunctional pNETs, the clinical presentations are more likely to be associated with the symptoms of
local compression and metastatic lesions, such as obstructive jaundice, pain and liver metastasis. In
addition, an increasing percentage of pNETs were diagnosed in asymptomatic patients who received
diagnostic evaluation for unrelated problems6.
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Clinical features- Functional tumors:
Functional PNETs are named for the hormone they hyper secrete. These PNETs tend to have better 5-
year OS compared with nonfunctional PNETs. This is likely because they are detected earlier than
nonfunctional PNETs, due to the presence of symptoms.
Insulinoma
Insulinomas represent 1% to 2% of all pancreatic tumors. They are typically small (<2 cm), solitary
(except in MEN1), intra-pancreatic, and cause symptoms of hypoglycemia. In the rare cases where
these tumors are malignant (in 10% cases), 5-year OS is 56%, and 10-year OS declines to 29%. A
critical part of the history includes establishment of the presence of Whipple’s triad: plasma glucose
less than 40 mg/dL, symptoms of hypoglycemia, and resolution of symptoms with a meal.
The diagnosis can be confirmed by drawing plasma glucose, insulin, C-peptide, and pro-insulin levels during a 72-
hour fast. This panel will detect 90% of insulinomas. Malignant insulinomas tend to produce higher levels of
insulin and pro-insulin and thus more severe symptoms due to the fact that their metastases also secrete these
hormones. Although most insulinomas are identified with computed tomography (CT) or ultrasound (US), when
they are very small these methods may not localize the tumor, and arterial stimulation venous sampling may then
be helpful. To perform this test, the right and left hepatic veins are catheterized via a femoral puncture. Calcium is
injected successively into the gastroduodenal, proximal splenic, superior mesenteric and proper hepatic arteries.
After each injection, venous blood is sampled from the hepatic veins at 30, 60, and 120 seconds, and a positive
localization corresponds to a twofold increase in hepatic vein insulin levels. The accuracy of this method to
localize the tumor to a region of the pancreas (i.e., head, body, tail) is 94% to 100%.

Gastrinoma
In 1955, Zollinger and colleagues published their case series detailing the clinical courses of two patients with
gastric acid hypersecretion, severe peptic ulceration, and pancreatic tumors. The extraordinarily high levels of
gastrin secreted by these tumors are the cause of the recurrent peptic ulcers, diarrhea, and reflux esophagitis
experienced by most patients and also cause the thickened mucosal folds in the stomach that are a hallmark of
the disease. These functional PNETs may be sporadic (67%) or familial (33%) and tend to be solitary tumors unless
seen in the context of MEN1, in which case they are small, multiple, and most likely found in the duodenum
(>85%). Regardless of their etiology, they are generally found within the gastrinoma triangle, which was described
in 1984 to aid surgeons in finding these frequently diminutive tumors. The majority of gastrinomas are considered
malignant (60%) and have spread to regional lymph nodes by the time they are diagnosed. Liver metastases are
often associated with gastrinomas that arise in the pancreas.
Laboratory diagnosis of the disease requires demonstration of hypergastrinemia and abnormal gastric acid
secretion. This can be done by obtaining a fasting serum gastrin and a gastric pH. If the gastrin level is 10
times normal and the gastric pH is less than 2, the diagnosis is confirmed. If results are equivocal, a
secretin or glucagon stimulation test can be performed, as gastrinomas frequently express both of these
receptors and respond by secreting abnormally large amounts of gastrin to the injected reagent.

Glucagonoma
These tumors are rare and tend to be large in size (>6 cm) and solitary pancreatic tumors. The most
common symptoms of the disease are glucose intolerance, migratory necrolytic erythema, and weight loss.
The migratory rash is often the first manifestation. It tends to start in the perineum and then spreads to the
trunk and extremities. The diagnosis is achieved when an elevated plasma glucagon level is found in the
context of an enhancing pancreatic mass on CT. Approximately 60% will have liver metastases at diagnosis.

VIPomas
VIPomas tend to be solitary, intra-pancreatic tumors, greater than 50% of which are metastatic at
presentation. The hypersecretion of VIP, a neurotransmitter and intestinal secretagogue, leads to the
development of “pancreatic cholera, also known as Verner-Morrison syndrome, which is characterized
by large volume (average, 4.5 L) watery diarrhea that leads to metabolic acidosis, achlorhydria, and
hypokalemia. If not properly identified and treated, patients will eventually succumb to renal failure
secondary to hypovolemia. As with the other functional PNETs, the diagnosis is made by radiographic
evidence of a pancreatic tumor and a history consistent with the syndrome associated with
hypersecretion of VIP. Further confirmation is made by demonstration of an elevated plasma VIP level.

Somatostatinoma
SSomas have a less-defined clinical syndrome than do the other functional PNETs, and not all tumors that
hypersecrete somatostatin will cause symptoms. The syndrome may include glucose intolerance,
cholelithiasis, weight loss, diarrhea, steatorrhea, or anemia. These tumors may arise either in the pancreas
(56%) or duodenum and may be more aggressive if intrapancreatic. Duodenal SSomas are associated with
NF1 in approximately 50% of cases. If discovered in this context, they are less likely to be malignant.

PPomas
PNETs that predominantly secrete pancreatic polypeptide (PP) are extremely rare, and whether they
should be classified as functional is a matter of debate, as no specific syndrome has been defined.
139
Patients may present with intermittent abdominal pain, pancreatitis, and some patients may develop
glucose intolerance. If these tumors occur in the context of MEN1, they tend to be multifocal and
malignant. PP can be used as a marker for PNETs in MEN1 patients, as fasting PP levels greater than
three times normal have been shown to correlate with the presence of a PNET that will likely be large
enough to detect by standard imaging.

NON FUNCTIONAL TUMORS:

Nonfunctional PNETs are characterized by their lack of hormone production and hormone-associated
syndromes. ~75% of PNETs are non functional. Patient mostly presents with symptoms related to the
tumor’s mass effect—abdominal pain, jaundice, weight loss, abdominal mass, nausea, vomiting, back
pain, or pancreatitis. Nonfunctional PNETs causing symptoms tend to be larger than those PNETs
found incidentally (2.5 vs. 1.8 cm) and are more likely to have involved nodes at diagnosis.

Approximately 35% of PNETs are discovered incidentally, and this is occurring with greater frequency as
the use of axial imaging is increasing. The benign tumors and those with uncertain histology were
associated with a 5-year OS of 89% and 93%, respectively, whereas malignant tumors had 50% 5-year OS.

GRADING AND STAGING

There are three guidelines for the pNETs, which are widely used including World Health Organization
(WHO) grading scheme7, European Neuroendocrine Tumors Society (ENETS) classification8 and AJCC
staging system9.The 2010 WHO classification system combined the differentiation and grading
features to classify the biological aggressiveness of pNETs based on the proliferative activity of the
tumor as measured by mitotic count and the expression of nuclear antigen Ki- 67.

Table 2: 2010 WHO grading system for PNETs

In general, well differentiated PNETs are either low or intermediate grade (G1 or G2) and are termed
neuroendocrine tumors (PNETs), while poorly differentiated PNETs are considered high grade (G3)
and are called neuroendocrine carcinomas (PNECs).
The AJCC and ENETs guidelines both have TNM/ staging systems. However, the two staging systems
differ from each other in the definitions of T stage groupings.
Table 3: The European Neuroendocrine Tumors Society (ENETS) staging definitions for pancreatic
neuroendocrine tumors

Table 4: AJCC staging for pancreatic neuroendocrine tumors

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Primary Tumor (T)
TX Tumor cannot be assessed
T0 No evidence of primary tumor
Tis Carcinoma in situ (includes Pan-IN 3)
T1 Tumor limited to pancreas, ≤2 cm in size
T2 Tumor limited to pancreas, >2 cm in size
T3 Tumor extends beyond the pancreas but without involvement of the celiac axis or superior mesenteric artery
T4 Celiac axis / SMA involvement

Regional Lymph Nodes (N)

NX Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
N1 Regional lymph node metastasis

Distant Metastasis (M)

M0 No distant metastasis
M1 Distant metastasis

Staging:

DIAGNOSIS:

IMAGING:

Computed tomography (CT) and magnetic resonance imaging (MRI)

CT and MRI are the most used and generally readily available techniques for the diagnosis of pNETs,
especially for nonfunctional pNETs, and has sensitivity and specificity over 80%. The images of
CT/MRI can be routinely reformatted in 2D or 3D image volumes to better display vascular anatomy
and contribute to surgical strategy. For the pNETs, CT has a mean sensitivity and specificity of 73%
and 96% respectively. For the liver metastases, mean sensitivity and specificity is 82% and 92%. When
the MRI techniques are chosen, the sensitivity and specificity is 93% and 88% for the detection of
pNETs, and the mean detection rate is 82% for the liver metastases 10. The drawback of CT/MRI is that
the sensitivity will be decreased in small tumors with a diameter less than 2 cm.

Endoscopic Ultrasound (EUS)

EUS provides high resolution imaging of the pancreas, and is suitable to detect small size (2-5 mm) pNETs
with mean detection rates of over 90%11. Furthermore, EUS can guide fine-needle biopsy for cytology or
core biopsy and provide a histological diagnosis for lesion of the pancreas and duodenum 12.

FUNCTIONAL IMAGING TECHNIQUES

Most pNETs (about 70%) express high levels of somatostatin receptors, mainly somatostatin receptor
type 2 (SSTR2), and can therefore be imaged with a radiolabelled form of the somatostatin analogue
octreotide (also known as somatostatin receptor scintigraphy, SRS), such as 111In-DTPA-octreotide
and 99mTc-EDDA/hydrazinonicotinyl-Tyr3-octreotide. SRS provides for scanning of the whole body
and allows detection of metastases outside of the abdominal region. Furthermore, SRS can offer
functional information based on the levels of somatostatin receptor expression and contributes to
selection of appropriate candidates for somatostatin-based therapies. However, SRS is limited by the
expression of somatostatin receptors. Poorly differentiated pNETs and insulinomas are less likely to
be detected and the SRS does not provide information on anatomy and surgical resectability13, 14.
Currently, the sensitivity of SRS has improved with the addition of single photon emission computed
tomography (SPECT). A novel class of somatostatin analogs labeled with the positron-emitting
radionuclide 68Ga for PET/CT imaging has emerged as the current gold standard for NETs. Combining
the advantages of PET/CT and affinity for the somatostatin receptor, the sensitivity of 68Ga for PET/CT
imaging for pNETs was reported to be around 90%15.

141
Tumor Markers
Tumor markers, including serum tumor markers and immuno-histochemical tumor markers, are useful
for the diagnosis and prognosis, especially with nonfunctional pNETs. Plasma Chromogranin A (CgA),
a most widely used serum marker, was found elevated in 88-100% of pNETs. However, the diagnostic
value of CgA is moderate in pNETs. Chromogranin A levels have been shown to correlate with tumor
burden, and post treatment decreases correlate with favorable outcomes, whereas rising levels may
suggest recurrent or progressive disease. The diagnostic sensitivity of CgA is less than 50% in
patients with small tumors, and increases to 60-100% in patients with metastases.
Therefore, serum CgA was used to reflect tumor burden, evaluate therapeutic response, and predict
survival outcomes for pNETs. Other serum markers include plasma neuron-specific enolase (NSE),
pancreatic polypeptide (PP), and pancreastatin. For functional pNETs, the specific peptides can be
used as a label for the diagnosis of a subset of pNETs, such as insulin and glucagon16, 17.

SURGICAL MANAGEMENT
Surgical resection of PNETs remains the only curative approach and must therefore be regarded as
the current standard of care even in many cases where advanced disease is found. However, only
about two thirds of the patients present with technically resectable disease.

LOW RISK DISEASE

PNETs show a benign biological behavior in 10%-40%, most of them being insulinomas. If benign
PNETs are solitary and easily accessible, local resection/enucleation is generally preferred.
In this respect, a recent study demonstrated the importance of intra-operative bi-digital palpation and
ultrasonography (IOUS) in localizing these lesions. Besides, IOUS is useful in clarifying the association of the
tumor lesions, the pancreatic vasculature and particularly, the main pancreatic duct. Therefore, it provides
important information in deciding between enucleation and resection. When the tumor is located further than 2-3
mm from the pancreatic duct, an enucleation is generally preferred to pancreatic resection19.

Furthermore, preoperative endoscopic tattooing of lesions in the pancreatic head or tail seems to be a feasible
alternative for intra-operative localization of the tumor especially for laparoscopic surgical procedures. When
enucleation seems possible, the tumor is carefully dissected off the surrounding pancreatic tissue. As an
alternative in cases where enucleation seems impossible, middle segmental pancreatic resection may be
performed as a parenchyma-preserving technique. Although parenchyma-preserving techniques have slightly
increased pancreatic fistula rate compared to standard resections, the patients do clearly benefit in terms of
pancreatic endo- and exocrine function. Organ preserving pancreatic surgery leads to
only 3%-5% impairment of endo- and exocrine function, whereas in standard resections this rate can
increase up to 21%-32%20.

There is an ongoing debate on the role of lymph node dissection in pNETs surgery. When considering
organ preserving surgery for low risk PNETs other than insulinomas, recent data showing a positive
lymph node status in up to 23% of low risk PNETs with significantly shorter disease free survival
(mean 4.5 years vs. 14.6 years; P < 0.0001) should be considered. The frequency of lymph node
metastases was reported to be higher for tumors > 15 mm, tumors in the head as compared to tumors
in the body and the tail, tumors with higher proliferation rates (G3), and with lymph vessel invasion 21.
In case of localized tumors, the aim of surgery is to achieve curative resection and to prevent or delay local or
metastatic recurrence. Here, oncological resections (pancreatico-duodenectomy or distal pancreatic resection) are
required. A recent study showed a survival benefit of 79 months for resected patients compared to those patients
who were recommended for but did not undergo resection (114 mo vs. 35 mo; P < 0.0001)22. However, in this
study, patients that were recommended for but did not undergo resection showed considerably more often distant
metastases when compared to the group of resected patients (58.3% vs. 28.4%). Nevertheless, the survival
advantage of resection appeared to hold true also for the subgroup of patients with distant metastases (60 mo vs.
31 mo, P = 0.01). Even though these data are retrospective, they suggest an impressive benefit of surgical
resection in extending survival. Furthermore, resection has been shown to reduce the risk for the development of
metachronous liver metastases. Patients with gastrinoma that underwent surgical resection developed
significantly less metachronous liver metastasis (5%) than those without surgery (29%) 23.
Interestingly, a margin-positive resection in locally advanced PNETs seems to offer a similar overall
survival compared to margin-negative resections24. Therefore, a resection of locally advanced PNETs
might even be attempted when margin-positivity is expected; however, a pre-operative assessment of
putative tumor biology is the key to successful PNET surgery.

Metastatic and recurrent disease

Liver metastases are commonly observed in PNET patients and are present in up to 60% at initial
diagnosis. At that point, only a small fraction of patients are technically and/or oncologically
resectable. However, the presence of both synchronous or metachronous liver metastases does not
generally represent a contraindication to surgical treatment of PNET patients.
142
It is still unclear when and whether the primary tumor should be resected in non resectable metastatic
disease. Concerning liver metastases, a significantly higher 5 year survival (72% vs. 25%) and a longer
median survival (96 mo vs. 20 mo) has been observed in resected patients compared to non-resected
ones25. A relevant oncological benefit can be achieved by palliative surgical debulking of more than 90% of
liver metastases, as also advocated by the recent ENETS guidelines 26. In the presence of bilobar hepatic
PNEN metastasis, resections may be performed safely in two-stage procedures in selected patients. In
addition, in the palliative setting, surgical cytoreduction has proven more efficient than transarterial
chemoembolisation alone. Another more recent option for the treatment of disseminated liver metastases is
the selective internal radiation therapy (SIRT) with yttrium-90 labeled glass microspheres.
This radio-embolisation therapy has been shown to be especially effective for the treatment of liver metastases of
colorectal and neuroendocrine tumors27. However, multi-disciplinary therapeutic approaches in specialized
centers are frequently required to maximize tumor mass reduction. In particular, surgical resection can be
complemented by other liver-directed therapies such as radiofrequency ablation (RFA) or trans-catheter arterial
(chemo) embolisation (TACE). Recurrence is a frequent finding and therefore reoperation for metastatic disease is
frequently needed and can result in excellent long term survival of up to 70% after 10 years. For early detection of
PNET recurrence, gallium-68 DOTATATE PET-CT may be helpful. PNETs with a KI-67 index of more than 5%,
positive lymph nodes, and tumor size > 4 cm are associated with a significantly higher risk for recurrence 28. These
data demonstrate that aggressive surgical resection can improve survival even in metastatic and recurrent
disease. In selected individual cases liver transplantation may be a treatment option, but evidence is limited and
the oncological outcome uncertain. Rosneau and colleagues reported 1-, 5- and 10-years survival rates of 89%,
80% and 50% in a study involving 17 patients29 which is not better than what can be achieved by
aggressivesurgical debulking. However, liver metastases of neuroendocrine tumors are not considered a standard
exception according to current waiting list criteria of UNOS and therefore these patients do not qualify for a
standard exception MELD. Steve Jobs, former CEO of Apple Inc., is the most prominent of these very select cases
and received a liver transplant for metachronous PNET liver metastases at the Methodist University Hospital
Transplant Institute in Memphis, Tennessee in 2009.

PNECS-HIGH GRADE DISEASE

Pancreatic neuroendocrine carcinomas with a high KI-67 index show an increased risk for recurrence and
metastatic disease and survival is poor30. Therefore resection in patients with poorly differentiated PNECs
with a high proliferation index should currently only be attempted when an R0 resections seems possible.
There is currently no role for cytoreductive surgery in these highly malignant cases. In advanced disease,
targeted therapies (e.g., VEGF and mTOR inhibitors) are increasingly acknowledged to be superior to
conventional chemotherapy in case of poorly differentiated PNECs.

PROGNOSTIC CONSIDERATIONS
For all PNETs, the 5- and 10-year survival rates are about 65% and 45%, respectively. Tumor grade plays a
significant prognostic role since patients with high grade PNETs have a much worse 5-year survival of less than
30%. Other positive prognostic factors include young age < 55 years and absence of distant metastases31. Of
these three parameters, Bilimoria and colleagues developed a prognostic score predicting survival after surgical
resection31. For this prognostic score, points from 0 to 3 are given for age (< 55 years = 0 points, 55-75 years = 1
point, > 75 = 2 points), differentiation (well/moderately differentiated = 0 points, poorly differentiated = 1 point), and
metastases (none = 0 points, liver = 1 point, other distant = 3 points). A prognostic score from 1 to 3 can then be
assigned where prognostic score 1 was defined as a total of 0 points, a prognostic score of 2 was defined as a
total of 1-2 points and a prognostic score 3 was defined as > 2 points. Using this scoring system – which can be
easily applied to every patient as soon as histology is available - Bilimoria and colleagues were able to show that
patients with a prognostic score 1 had a favorable 5 year survival of 76.7% compared to 50.9% for prognostic
score 2 and 35.7% for prognostic score 3. While these data have been generated retrospectively and a validation
on an independent cohort is lacking, this tool may still be helpful in estimating patient’s survival and may
therefore assist in adjuvant treatment decisions.

SYSTEMIC MEDICAL MANAGEMENT

While the primary treatment for pNETs is surgical, the treatment of patients with advanced or
metastatic disease requires a multidisciplinary approach. Nonsurgical therapeutic approaches include
chemotherapy, biotherapies, targeted therapies, peptide receptor radiotherapy (PRRT), local ablation
and interventional therapy.

CYTOTOXIC CHEMOTHERAPY
The pNETs demonstrate a relative sensitivity to chemotherapy. However, there is no established standard
chemotherapy for this disease and the chemo sensitivity varies with type and differentiation status. The
poorly differentiated (G3) pNETs have a better response than the well differentiated (G1/G2)pNETs.
First-line therapy is traditionally platinum with etoposide for pNECs and presents a response rates
from 31% to 67%. pNETs Patients with a lower proliferative rate (Ki- 67 < 55%) had a lower response
rate to chemotherapy (15% vs. 42%) but a better overall survival (OS) (14 vs. 10 months) compared
with patients with a Ki-67 over 55% .
143
Well differentiated pNETs proliferate slowly and are generally resistant to most chemotherapeutic
agents with reported response rates varying from 8% to 45%. Given these findings, the oral alkylating
agent temozolomide, particularly in combination with capecitabine, has shown promise. In a series of
30 patients treated with temozolomide in combination with capecitabine, 70% of patients
demonstrated a radiographic tumor response.32

SOMATOSTATIN ANALOGUES (SSAS)

SSAs have shown a significant impact on functional pNETs patients with hormonal symptoms. Furthermore,
SSAs also have cytostatic effects that can stabilize metastatic disease without tumor regression in most
cases. The SSAs currently available in clinical practice are octreotide and lanreotide. Two phase III
controlled studies of SSAs anti-proliferative response in neuroendocrine tumor trials, CLARINET trial and
PROMID trial, both have significantly better progression-free survival (PFS). Although, SSAs have long been
the workhorse in medical NET therapy, combination with newer targeted therapeutic agents is the most
used type of treatment and may further improve outcomes33, 34.

PEPTIDE RECEPTOR RADIOTHERAPY (PRRT)

PRRT is a newer treatment option that can be used for tumors that express a high density of somatostatin
receptors on somatostatin receptor imaging. This is approved for use in Europe and is being studied in trials in
the United States. One series of 504 patients with gastroenteropancreatic NETs treated with Lu-177 labeled PRRT
reported complete and partial tumor response in 2% and 28% of patients respectively 35. The first phase
trial of PRRT, NETTER-1, demonstrated a significant increase in the median PFS duration of patients with
midgut NETs who received DOTATATE compared with those treated with LAR octreotide 36.

TARGETED THERAPY
mTOR inhibitors
As aberrant mTOR pathway genes have been found in 16% of pNETs, it is expected, then, that inhibiting
mTOR signaling would inhibit tumor growth in at least a subset of patients. The oral mTOR inhibitor
Everolimus has been extensively studied in GEP-NETs. A randomized phase III study evaluating the
efficacy of Everolimus in advanced pNETs had been demonstrated to prolong PFS duration in patients
with advanced-stage pNETs when compared with placebo. As a result of the significant improvement in
PFS, Everolimus was approved by the FDA for treatment of patients with advanced pancreatic NETs37.

ANTIANGIOGENESIS
PNETs are highly vascularized neoplasms and express an abundance of VEG-F and platelet-derived
growth factor (PDGF) receptors. This characteristic is associated with the over-expression of both
ligand and related receptor of vascular endothelial factor (VEGF).
Bevacizumab is a humanized monoclonal antibody that inhibits VEG-F and has not yet been approved by
the FDA for use in pNETs. Combination therapy with bevacizumab has also been investigated in pNETs.
Combination therapy with mTOR inhibitor temsirolimus and bevacizumab showed a response rate
(RR) of 41%38.

SURVEILLANCE AND FOLLOW UP

National Comprehensive Cancer Network (NCCN) guidelines for the surveillance and follow-up of PNETs: If a
patient has been resected, biochemical markers and a contrast-enhanced CT or MRI should be obtained at least
once in the 3 to 12 months after surgery. Thereafter, if the patient does not recur, they should be followed every 6
to 12 months for 10 years with an examination, appropriate NET laboratory tests (CgA, PST), and consideration of
either CT or MRI. The exception to this would be in the case of a benign insulinomas, which may only need to be
followed for 1 to 2 years unless the patient had multiple lesions or has MEN1. If the patient experiences a
recurrence, has G3 disease, or has loco regional or distant unresectable disease, follow-up will be determined by
the patient’s clinical condition and the behavior of the tumor.
An asymptomatic patient with a low tumor burden can be followed every 3 to 12 months with
biomarkers and imaging. Onset of new symptoms or evidence of disease progression should prompt
more frequent follow-up.

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 EMERGENCY AIRWAY MANAGEMENT FOR SURGEONS
-Dr.Rakesh kumar

INDICATIONS
Surgical patients in Casualty and Emergency
Ward -Unconscious or semi-conscious
Peri-operative period
-Thoracic & Upper abdominal
surgeries -Thoracic & Upper
abdominal trauma -Airway trauma
-Thyroid surgery
-Post-anesthesia, not fully alert

HOW TO IDENTIFY AIRWAY OBSTRUCTION OR RESPIRATORY INADEQUACY

LOOK
1. Restlessness 8. Tracheal tug
2. Excessive/Paradoxical movements 9.Convulsion
3. Choking 10. Recession
4. Accessory muscles 11. Blank’ cough attempts
5. Central cyanosis 12. Flushed skin and sweating
6. SpO2, ETCO2 13. Alae nasi
7. Tachy-arrhythmias 14. Visible secretions

LISTEN
1. Snoring 5.Conducted sound
2. Gurgling 6.Silent chest
3. Weak cough 7.Alarms on monitor
4. Stridor 8.Confusion

FEEL
1. Expired air 3. Pulse
– Reduced – Rapid, Bounding
– Absent – Irregular
– Absent
2. Skin
– Warm 4. ‘Stiff’ bag
– Moist 5. Sound

REACTING TO AIRWAY EMERGENCY

Call for help
Maintain oxygenation
Nasal prongs
maximum O2 from flowmeter
Look for and treat the underlying cause
Drain offending agent
Air – Pneumothorax, Subcutaneous emphysema
Blood – Hemothorax, Hemoperitoneum, Postthyroidectomy hematoma
Pus/ Edema – Cellulitis around airway

Relieve splinting – Drain peritoneal cavity

Relieve pain
Reverse sedation/ anesthetic/ muscle relaxant
Airway Opening Maneuvers
Relief of choking

Mild obstruction
The patient is able to breathe, cough effectively and speak.
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 Children are fully responsive, cryin g or verbally respond to questions; may have a loud cough (and
be able to take a breath before coughing).
Severe obstruction
Inability to breathe or speak/vocalize.
Wheezy breath sounds.
Attempts at coughing that are quiet or silent.
Cyanosis and diminished consciou s level (particularly in children).

Management
Mild obstruction
Encourage the patient to continue co
ughing Monitor the patient
Severe obstruction
Conscious patient:

Heimlich’s maneuver:
Stand to the side and slightly behi nd the victim, support the chest with one hand and lean the victim well
forwards (so that the obstructing object comes out of the mouth rather than going furthe r down the airway).
Give up to five sharp back blows between the shoulder blades with the heel of your other hand
(checking after each if the obstruction has be en relieved).
If unsuccessful, give up to five ab dominal thrusts. Stand behind the victim (who is le aning forward),
put both arms around the upper abdo men and clench one fist, grasp it with the other hand and pull
sharply inwards and upwards.
Continue alternating five back blo ws and five abdominal thrusts until successful or thhe patient
becomes unconscious.
Unconscious patient:
Lower the patient to the floor.
Call an ambulance immediately.
Begin CPR (even if a pulse is prese nt in the unconscious choking victim).

Relief of airway obstruction

Manual methods: head tilt, chin lift, jaw thrust
Device based methods
– Suctioning
Oro-pharyngeal suctioning
Naso-pharyngeal suctioning
Through tubes in the airway: 1) Endotracheal tube 2) Tracheostomy tube

Steps of suctioning
Actuate the suction – Switch ON; or – Pump the piston (Foot/ Hand operated)
Adjust the pressure to get the rig ht suctioning force (80-120 mmHg is usually enough)
Connect the suction catheter
Switch to 100% oxygen for a few seconds
Monitor the patient’s hemodynamics and, preferably, his SpO2
Instill 2ml of 2% lidocaine into the tube – Continue giving O2 while waiting for 10-15s ec
Choose a sterile flexible catheter that has an external diameter that is less th an half the internal
diameter of the tube in the airway
Insert the catheter into the tube without touching it
Do not suction while inserting the catheter (keep the side opening open)
Apply suction by occluding the s ide opening of the catheter and start withdrawing it slowlywhile
making gentle rotating movements as w ell
Do NOT suction for more than 10 seconds in one go
Give 100% oxygen to the patient for 1-2 minutes before attempting the next round

– Oro-pharyngeal airway

147
– Naso-pharyngeal airway

– More advanced devices

Supra-glottic airway devices (SADs)

Ambu Laryngeal Mask

Laryngeal Tube Suction (LTS)

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 When everything fails
Jet ventilation
Cricothyroidotomy
Canula
Scalpel:
Stabilize larynx &identify cricothyroid membrane
Make transverse stab incision through the skin & cricothyroid membrane
Turn perpendicular scalpel through 90° so that the sharp edge points caudally
Swap hands; scalpel in Lt hand.
Pull straight scalpel toward s you (laterally).
Slide the bent tip of bougie down the side of the scalpel blade furthest from y ou into the trachea.
Align the bougie with patient’s trachea and advance to 10–15cm
Remove scalpel.
Stabilize trachea and railroad a lubricated size 6.0 mm cuffed tracheal tubes o ver the bougie.
Remove the bougie.

SPECTRUM OF AESTHETIC SURGERY

-Dr. Rajat Gupta, D r. Priya Bansal

As a general surgeon, we have very less of an idea about spectrum of Cosmetic Surgery. T his chapter gives a very
brief outline about each cosmetic surgery procedures. Cosmetic Surgery is an art along with science. There is beauty
in every body part god h as designed. Sometimes either with age or congenitally, some or other body part are not as
desired by any indi vidual. Here comes the role of cosmetic surgery. Spectrum ranges from head to toe. Here we will
be describing a bout most common cosmetic surgeries done in our practice.

BROW LIFT

ANATOMY
Eyebrow level is the result of a balance between the muscular forces which elevate the brow, the muscular
forces which depress the brow, and th e universal depressor: gravity. Eyebrow complex b ecomes ptotic with
age, lateral portion being more sensitive to this interplay because frontalis action is attenuate d laterally.

THE IDEAL BROW

The medial eyebrow level- over the medial orbital rim.
The medial border-vertically in line with the medial canthus.
Peaking slightly at least two-thirds of the way to its lateral end; vertically above the lateral limbus.
The lateral tail- higher than the medial end.
The male brow-lower and less peaked .

SURGICAL APPROACHES
CORONAL BROW LIFT - No longer the gold standard for brow elevation, disadvantage s being a long
scar, disruption of hair follicles, and scalp dy sesthesia.
ENDOSCOPIC BROW LIFT- Advantage being shorter incisions and fixation is as effective as any other
form of brow lifting.
LATERAL BROW APPROACH - incis ion in the temple, lateral to the temporal crest line to avoid injury
to the deep branch of the supraorbital nerv e; dissection carried out with an endoscope; combines
advantages of both.
TRANSPALPEBRAL APPROACH- performed through the upper blepharoplasty incision. Dissection
performed under the orbicularis, and brow tissue sutured directly to the periosteum o ver the
supraorbital ridge.
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BLEPHAROPLASTY
ANATOMY
The upper eyelid crease is formed by the insertion of the levator aponeurosis into the dermis. The lid fold
is formed by excess skin and muscle that overhangs the crease. In the Occidental eyelid, the crease is
approximately 7 mm above the lash margin at the mid-pupillary line in males and 8 to 10 mm in females.
In the Asian upper eyelid, lid crease is u sually absent. With aging, loss of skin elasticity pre sents as
periorbital rhytids and the eyelids become puffy due to orbital fat bulging through the weakened orbital
septum. The combination of soft tissue loss and desc ent around the fixed points of the retaining ligame
nts creates an aged surface contour. Brow ptosis accentuates the amount of loose skin in the upper lid.

Preoperative evaluation
Brow position
Lower eyelid tonicity
Eyelid ptosis, retraction, or levator dehiscence
Exophthalmos or enophthalmos
Supraorbital rim prominence or hypopl asia
Suborbital malar and tear trough defor mities

UPPER LID
Simple skin blepharoplasty - Lower incision at the level of lid crease, upper incision depending on skin
excess
Orbital fat excision- Small septotomy made into each fat compartment in which conservative resection of
redundant fat done
Asian Blepharoplasty - Lower incision at the level of proposed lid crease, upper incision 2mm above this.
Excision of skin, muscle, and preapone rotic fat, followed by multiple sutures through the j nction of the
upper tarsal margin, levator aponeurosis, and dermis of the skin margin.

LOWER LID
Transcutaneous approach- Preferred in patients with excess skin, subciliary incision give n, skin muscle
flap raised, excess orbital fat excised or repositioned.
Transconjunctival approach- For younger patients, preseptal or retroseptal approach may be used to
deal with the orbital fat.

FACELIFT

Stigmata of aging face:

Changes in skin, including folds, wrinkles, dyschromias, dryness and thinning
Folds createdby chronic muscle contraction: glabellar frown lines, transverse forehead lines, and crow’s feet.
Deepening folds between adjoining anatomic units: the nasojugular fold (tear trough), naso
labial folds, marionette lines and submental crease
Ptosis of soft tissue, lower chee k, jowls and neck
Loss of volume which creates ho llowing of the temple, the lateral cheek and the central cheek
Expansion of volume in the neck and lateral jaw line which leads to the formation of jowls and
fullness of the neck

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APPROACHES
SUBCUTANEOUS -Effective when the only significant problem is loose skin. Advantages-rapid
postoperative recovery, does not risk damage to the fa cial nerve or other deep structures.
Disadvantage-longevity of effect is in question, minimal effect on underlying facial shape.
SMAS PLICATION- Creates an infolding of the superficial fat, drawing fat from the lower i n the face up to
the point where the sutures are placed. Disadvantages- loss of effect if sutures cut through the soft
tissue, the degree of improvement may be limited b y the tethering effect of the retaining ligaments.
MACS LIFT- Long suture loops which ta ke multiple small bites of soft tissue fixated to the deep temporal
fascia just superior to the zygomatic arch and anterior to the ear. More firm point of fixation compared to
plication technique.
SMASECTOMY- Strip of SMAS and ov erlying fat is removed, angles obliquely from the an gle of the
mandible to the lateral canthus. Fixation is pote ntially more secure than plication alone, but lack of any
ligamentous release may limit the movement of certa n tissues.
DEEP PLANE FACELIFT- Raising skin, subcutaneous fat, and the SMAS as a single layer ; monobloc-
moved in one direction, thick robust flap
DUAL PLANE FACELIFT- Moving the skin and subcutaneous soft tissues along different ve ctors result in more
accurate reversal of the aging process. Disadvantage of excess skin tension is avoided. P otential damage to
deep structure and problems with the sk in flap if it is too thinly dissected or placed on too mu ch tension.
SUBPERIOSTEAL FACELIFT- Limited effect in the lower face/neck region and limited effect on superficial
structures, particularly loose skin. Hence, for younger patient who requires midface improv ement
without skin tightening.

NECK
Aging in the neck may be due to skin excess, fat accumulation, platysma laxity, digastri c or
submandibular gland abnormalities. Improvement is predicated upon:
Skin release from retaining ligament s and septae
Appropriate fat removal from the sub cutaneous (superficial) and sub- platysmal (deep) plane
Alteration of the platysma and on oc casion the digastric muscles
(4) Submandibular gland alteration.
It is the rare patient who will be best treated by neck surgery alone. The maneuvers described should be
considered as part of the facelift techniq ue.
LIPOSUCTION- ideal patient for neck liposuction is the relatively young patient with good skin elasticity
who has localized submental and submandibular fat.
ANTERIOR (SUBMENTAL) INCISION- Depending upon the requirement one or all of the following may be
done: Subplatysmal and interplatysmal efatting; Medial platysmaplasty/platysma tightening; Platysma
plication over the submandibular gland; Submand ibular gland resection.

RHINOPLASTY

ANATOMY
The osseocartilaginous nasal framework is comprised of three separate vaults:
The bony vault(paired nasal bones an d the ascending frontal process of the maxilla)
The upper cartilaginous vault(paired u pper lateral cartilages)
The lower cartilaginous vault(the medial, middle, and lateral crura of the lower lateral cartilages)
The septum comprises the septal cartilage, the perpendicular plate of the ethmoid, the nasal crest of the
maxilla, and the vomer.

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NASOFACIAL ANALYSIS
The nasal length (radix to tip, or R-T) sh ould be equivalent to the stomion-to-menton distance (S-M)

The normal alar base width is equi valent to the intercanthal distance. The bony base should equal
approximately 80% of the alar base widt h.
The degree of tip rotation is assessed b y evaluating the nasolabial angle. This angle is us ually 95° to
100° in women and between 90° and 95° in men .

The dorsum is analyzed by drawing a line from the radix to the tip-defining points. In women, the ideal aesthetic
dorsum should lie approximately 2 mm behind and parallel to this line, but in men, it should a pproach this line.

Tip projection is addressed by drawing a horizontal line from the alar-cheek junction to the tip of the
nose. The distance between these points should eq ual two things:
The alar base width
0.67 × R-T.

OPEN RHINOPLASTY
Particularly advantageous in (a) posttra umatic deformities, where complete release of all intrinsic and
extrinsic deforming forces is necessary, (b) secondary/revisional surgery,and (c) when complex ti p
modifications are necessary.

Advantages-
Binocular visualization
Evaluation of complete deformity with out distortion
Precise diagnosis and correction of deformities
Allows use of both hands
More options with original tissues and cartilage
grafts Direct control of bleeding with electrocautery
Suture stabilization of grafts (invisible and visible)

Disadvantage-
External nasal incision
Protracted nasal tip edema

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Incision

Component dorsal hump reduction

Separation of the ULC from the septu m
Incremental reduction of the septum proper
Incremental dorsal bony reduction
Verification by palpation

Correction of the Deviated Nose

Open approach
Release of all mucoperichondrial attac hments to the septum, especially the deviated part
Straightening of the entire septum while maintaining a 10 mm caudal and dorsal L-strut
Precisely planned and executed external percutaneous osteotomies

Tip Refinement

Use of cephalic trim

Nasal tip suture techniques, and
Cartilage grafting

Osteotomies
Indications:
To narrow the lateral walls of the nose
To close an open-roof deformity (after dorsal hump
reduction); and To create symmetry
Contraindications:
Short nasal bones
Elderly patients with thin, fragile nasal
bones Patients with heavy eyeglasses

CLOSED RHINOPLASTY
Advantages
Leaves no external scar
Limits dissection to areas needing mo dification
Permits creation of precise pocket so graft material fits exactly without need for
fixation Promotes healing by maintaining vascular bridges
Produces minimal postsurgical edema
Results in fast patient recovery
Creates intact tip graft pocket
Allows composite grafting to alar rims

Disadvantages
Requires experience and great reliance on accurate preoperative
diagnosis Does not allow direct visualization of nasal anatomy
Makes dissection of alar cartilages difficult, particularly in cases of malposition

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Incision

HAIR RESTORATION SURGERY

Follicular units refer to the naturally occu rring clusters of, typically, one to four hairs that em erge from
the scalp. In all men even with grade VI or VII ba ldness there is a zone in scalp at the back of our head
which is hair bearing and shall remain so up to 80–9 0 years of age. This zone is called permanent or s
afe donor area. The science of hair transplant is to harvest the hair follicles from this permanent zone
and subs equently transplant them to the bald zone Also a decent area of the donor has to be preserved
for subsequent hair transplant if the patient needs it after a few years specially those in early twenties.

Follicular Unit Transplant

A strip is harvested up to the depth of the hair follicle bulb encompassing the subcutaneou s fat and dissected
under magnification into small slivers. These slivers are then further dissected into each follicular unit.
Meanwhile the donor site is closed by a special technique called trichophytic closure whe re one edge of cut
margin is just de epithelialized for 1–2 mm followed by a closure skin to skin leading to innocuous scar.

Follicular Unit Extraction

Hair follicles are cannulated by a small punch usually motorised and the follicle is pulled out carefully
with the help of a forceps. Direction of the punch and its extraction is the same as the direction of h air
follicle inside the scalp. These small punches consequen tially heal to leave small moth eaten scars. One
should harvest only one-third of follicles so that the donor sit e does not look bald.

Hairline Designing
The final result should be a natural-a pearing hairline and natural-appearing density an d requires-
locating appropriate borders;creating micro- an d macro-irregularities; maintain the correct angle and
direction of implantation.

Preparation of the Recipient Area

Anaesthetized by giving blocks of bilater al supratrochlear and supraorbital nerves. Tumesc ence is created
with normal saline. Slits are made in the correct angle and direction to place the follicular graftss. During this
whole process one should ensure that the grafts are kept wet with cold saline to prolong their survi val time.

LIPOSUCTION

ANATOMY
Subcutaneous fat throughout the body is divided into superficial and deep compartments se parated by
Scarpa’s fascia. In the trunk and thigh, deep fat consists of larger lobules arranged loosely an d is the
target for liposuction. The overlying superficial fat is relatively thin and acts as a protective layer to hide
small contour deformities.
Zones of adherence - Areas with relative dense fibrous attachments to underlying deep fa scia, which
helps in defining the natural shape and curve of the body. They are the high-risk areas for contou r
irregularities if not properly respected.
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Infiltrates

Liposuction techniques
Suction-assisted liposuction (SAL) - Blunt-tip cannulas attached via tubing to a sourc e of high vacuum,
which effectively suctions fat through holes in the tip of the cannula. More difficult to use in fibrous
areas, more physical work involved, increased operat ive time, more bruising.

Power-assisted liposuction (PAL) - Externally powered cannula oscillates in reciprocatin g motion at

rates of 4000–6000 cycles/ min. Breaks up fibrou s fat much more readily, faster and less labor intens ive

Ultrasound-assisted liposuction (UAL) - Ultrasonic energy causes micromechanical, thermal, and

cavitational effects on subcutaneous fat with less disruption of vasculature, less bruising.
Disadvantages are frictional injury at the skin entry site, pos sibility of thermal injury.

Vaser- assisted liposuction- Newer g eneration ultrasound-assisted liposuction device w ith grooves on
the end of probes which allow better lateral fragmentation of tissue with lower energy, decreasing its
thermal component to the tissues.

Laser-assisted liposuction (LAL) - In sertion of a laser fiber via a small skin incision, ac ts to disrupt fat
cell membranes and emulsify fat, purported skin-tightening effects by heating of the subdermal tissue.

Surgical endpoints
Primary- Skin pinch and final contour
Secondary- treatment time, blood in asp rate and amount of aspirate

155
ABDOMINOPLASTY
ANATOMY
Huger defined zone I of the abdominal w all as the area fed anteriorly by the deep epigastric arcade, Zone
III fed by the six lateral intercostal and four lumbar arteries and Zone II by the superficial ep igastric,
superficial external pudendal, and superficial circumflex iliac systems. A rich plexus between these
systems allows collateral flow. During abdominoplasty, the mobilized abdominal flap is dependent on th
e lateral perforating branches from the lateral intercostals and lumbar arteries. Hence it is imperative to
preserv e these vessels and crucial to study any preoperative existing scar.

MINI-ABDOMINOPLASTY
Candidate-Minimal abdominal wall laxity restricted to the infraumbilical region. Lower incision is marked
in the patient's natural suprapubic crease and a distance of at least 9 cm between the upper re section
line and the umbilicus should be respected to avoid an unaesthetic appearance. The abdominal flap is
raised cranially on the epifascial surface of Scarpa’s fascia up to the level of the umbilical stalk.

STANDARD ABDOMINOPLASTY
Candidate-laxity involves the supra and infraumbilical regions, limited to the anterior aspects of the lower trunk. The
inferior incision line is marked in t he natural suprapubic crease and then carried laterally towards ASIS. Then in the
supine position, the expecte d amount of resection is assessed and upper incision line marked but incision is not
made until the end of the procedure after intraoperative assessment of the correct tissue resection. Undermining is
mainly performed in the midline area anterior to the linea al ba and both rectus muscles. Contour of the rectus
muscle may be restored by midline plication of the rectus fascia. With the abdominal flap approximated to the low er
incision, the position of the umbilicus is noted an d a neo-umbilicus is created which should be fairly small, ver tically
oriented, superiorly hooded, and contains the scar on the inside.

FLEUR-DE-LIS ABDOMINOPLASTY
Candidate- Horizontal and vertical redundant tissue in the lower and upper abdomen. Ind dependently
assess and mark the horizontal and vertical surplus of skin and fat tissue. Advantage-create more waist
definition, and decrease lateral fullness. Drawback –ver tical midline scar.

CIRCUMFERENTIAL ABDOMINOPLAS TY/BELT LIPECTOMY

Candidate- Massive weight loss patients with laxity involving the lateral and posterior aspec ts of the lower
trunk besides the anterior trunk. A wedge of tissue is marked for proposed excision around th e lower trunk.
The wedge brings a narrower part of the co ne down to the level of a wider part of the cone loc atednear the
pelvic brim. Anterior aspect of the wedge is wid er (in vertical distance) than the lateral or posterior aspects.
The lateral resection is the next widest The final s car is located above the widest aspect of the bony pelvic
brim, at the junction between the lower back and buttocks, which may be visible outside of undergarme nts but
because this allows cinching at waist level, more wais t definition is achieved.

REVERSE ABDOMINOPLASTY
Candidate- Massive weight loss patient with persistent skin and soft tissue excess of th e upper
abdomen. Inframammary fold is marked as upper incision line, surplus of tissue and the consequent
lower incision line is assessed by pinching.

LOWER BODYLIFT
Candidate- Massive weight loss patients . The bilateral zones of adherence are destroyed t o allow the
surgeon to lift the lateral and anterior thighs after extensive undermining. Since the circumferential w
edge of excision is low, it creates a fairly low scar that can be covered by undergarments. However, the
waist is not narrowed as much and the scar runs across in the midst of the upper third of the buttocks
unit both of w hich is not desirable in a female.

INNER THIGH LIFT

Candidate- Mild to moderate inner thigh laxity. Upper incision line lies along pubic thigh cre ase.
Posteriorly, the markings end before they become visibl e in posterior view. Anteriorly, the markings
extend a pproximately to the level of the pubic tubercle.

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VERTICAL THIGH LIFT
Candidate- Massive weight loss patients with significant medial and circumferential thigh laxity. The
markings begin at the insertion of gracilis muscle and extend to the inferior level of the deformity.

BRACHIOPLASTY
Candidate- Vertical and horizontal skin excess and willing to accept scar along the medial arm. The
first marking is the biccipital groove, the desired final position of the scar. Proximal extent of the
incision is set high in the axilla.

MINI BRACHIOPLASTY
Candidate- moderate amounts of skin and fat excess in the proximal third of the upper arm. Scars
limited to the axillary region, only addresses skin excess in the longitudinal direction.

LATERAL THORACIC EXCISION

Candidate-excess of lateral chest wall. Excess skin and fat of the upper chest is pulled anteriorly and
vertical line is drawn from the axilla to the inframammary fold. This represents the line of the final scar.

BUTTOCK AUGMENTATION
Gluteal augmentation is not just about making the buttock bigger, but rather accentuating, contouring, and
reshaping. Liposuction is for sculpting, while fat transfers and/or implants are used for volume expansion.

FAT GRAFTING- It includes performing liposuction to create a deep sacral “V”, which will enhance the superior
gluteal cleavage, accentuated by grafting the upper medial buttocks. The areas of maximum prominence should
be at the junction of the middle and central thirds transversely and the mid and upper poles of the buttocks.

IMPLANTS- Intramuscular plane (location of choice).This plane disrupts the muscular fibers of the
gluteus maximus. The goal is to have 2–3 cm of muscle over the pocket and to leave 3 cm thickness of
gluteus maximus deep to the pocket to protect the sciatic nerve.

GENITAL AESTHETICS

PENILE ENLARGEMENT
Penile lengthening- releasing the suspensory ligament of the penis and the postoperative use of
penile weights or stretching devices
Girth increase treatment- fat injections into the dartos fascia; inserting either dermal or dermal fat
strips into the dartos fascia.

SCROTUM REDUCTION
Enlarged and low-hanging scrotum secondary to increased laxity from aging. Treated by horizontal
excision of mid and upper scrotum.

LABIAPLASTY
Labia minora
Enlargement with age, after childbirth, chronic irritation, or hormones.
Excising or trimming the abnormal areas and oversewing them.

Advantages: short operative time and the creation of light colored labial edges.
Disadvantages: replacement of normal labial edge with a longitudinal scar with high incidence of
chronic discomfort.

Central wedge technique- Excises a wedge or ‘V’ of the most protuberant labium and reapproximates
the edges; preserves the normal anatomy of the labial edge; longer operative time, more surgical
expertise, and occasional persistence of darker labial pigment

Labia majora
Result from an overly fatty majora or a majora with excess skin Excess hanging skin can be
congenital, postpartum or caused by weight loss or aging.
The skin excess is removed bilaterally from the medial portion of each labium as a crescent excision
extending from the anterior to the posterior labial commissures. Incision line is usually placed just
lateral to the medial hairline.

HYMENOPLASTY
Sought for the purpose of tightening of the hymenal ring to produce difficult entry with probable
tearing and concomitant loss of small amount of blood. Done by several small excisions, just inside
the hymenal ring which are closed vertically, producing a size compromised aperture.
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VAGINOPLASTY
Repair of the posterior vaginal wall and introitus are the key components. Prolapse must be ruled out/corrected first.
Trapezoid incision is made at the i ntroitus which is continued vertically on the posterior wall. Rectovaginal fascia is
plicated in several layers to red uce the hiatus. Small amount of vaginal epithelium iss also excised.

GYNAECOMASTIA
In patients with gynaecomastia for more than 1 year and with a normal history and physical examination,
surgery may be indicated. Simondivided gynaecomastia into four grades: grade 1: small e nlargement,
no skin excess; grade 2a: moderate enlargeme nt, no skin excess; grade 2b: moderate enlargem ent with
extra skin; grade 3: marked enlargement with extra skin.

LIPOSUCTION
A lateral incision at the level of the infra mammary fold is made. Suction/Power/Ultrasonic as sisted
liposuction is done. The patient is treated with a co mpression vest and the chest wall tissue is given
time to settle and contract. Almost all grades can be tre ated by this technique and in majority of cases, n
o skin resection is required. When skin resection is perform ed, the amount of skin removed and the
length of th e incisions are less than if the resection had been performed at the time of the initial surgery

PULL THROUGH TECHNIQUE

When liposuction is unsuccessful at removing all of the tissue required to achieve a go od result, the
pull-through technique is added. In this tech nique, the lateral incision is opened slightly and th e
residual tissue is grasped and pulled out through the wou nd and removed.

PERIAREOLAR GLAND EXCISION

When the gland is more fibrous and not amenable to the above techniques, surgical exci sion is chosen.
The skin incision is placed at the junction of the areola and skin. A cuff of tissue 1 to 1.5 cm in thickness
is preserved directly deep to the nipple-areola complex.

BREAST AUGMENTATION
BREAST IMPLANT
Implant size
Philosophy-Give the patient the size that fits within her breast tissues. Various methods have been
employed by different surgeons to decide upon the size. TEPIDTM System published by Tebbetts based
upon breast measurements of tissue thickness, stretc h, and breast fill is the most widely referenced.
Pocket location
Subglandular (between the breast and the pectoralis fascia)- most anatomically corre ct position; a
pinch test result of >2 cm is required.
Subfascial (between the pectoralis muscle fascia and the pectoralis muscle)- With only 0.2 to 1 mm more
coverage, this procedure is a variation of the subglandular pocket and does not qualify as a distinct pocket type.
Dual plane (pectoralis major musc le over some parts of the implant and breast ov erotherparts of the
implant)-when skin pinch <2 cm; drawback-muscle animation.
Incision
Inframammary-allows the greatest degree of control and precision; does leave a visible s car(4-5cm)
Periareolar- heals inconspicuously. D isadvantages- transection of the parenchymal du cts (often
colonized with Staphylococcus epidermidis), risk of nipple sensitivity changes
Trans-axillary-can be performed with the aid of endoscope; avoids any scarring on the breast mound;
precise implant placement can be more difficult.
Transumbilical- can be used only wit h saline implants

FAT GRAFTING
Contour deformity after implant reconstr uction- sharp implant borders and visible rippling ca n be
softened by fat grafting.
Primary breast augmentation-the enlargement is less reliable and less certain; increase th e breast by 1/2
to 1 cup size; percentage of fat survival is the key with about 30-40% resorption rate.

BREAST REDUCTION
ANATOMY

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Two decisions confront the surgeon:
Choice of incision (scar) pattern –periareolar; vertical/lollipop; inverted T
Choice of pedicle type

Inferior Pedicle
An inferiorly based dermoglandular pe dicle is planned with a base of 4 to 9 cm at the IMF. Skin and
parenchymal resections are performed m edial and lateral to the pedicle and also superior to the nipple- areola.

Central Pedicle
The medial and lateral inferior quadrants of breast; as well as the central inferior tissue intervening between the
nipple-areola and the IMF, are excised a s a single curvilinear, ellipsoid unit. Skin incision at the superior aspect of
the keyhole is deepened only enough to allow comfortable transposition of the central mo und pedicle.

Medial pedicle
The key is to leave a Wise pattern of parenchyma behind and to close both the pillars a nd the skin
without tension. It makes more sense to remov e the heavy inferior pole than it does to remove t he upper
pole. The inferior border of the medial pedicle becomes the medial pillar and the pedicle rotates into
position without any compression or kinking
Superior pedicle
Similar to medial pedicle, it leaves a Wis e pattern of parenchyma behind; more robust bloo d supply. A
superior pedicle can be difficult to inset because it usually needs to be folded and it is often necessary
(and safe) to thin the pedicle to allow for an easier inset.

MASTOPEXY

Breast ptosis classification by Regnault:

Minimal ptosis: the nipple is at the lev el of or just inferior to the inframammary crease.
Moderate ptosis: the nipple is 1–3 cm below the inframammary crease.
Severe ptosis: the nipple is >3 cm below the inframammary crease.
Glandular/pseudoptosis: the nipple rests above the inframammary fold but the majority of breast tissue
rests below.
Goal is to restore a firm and youthful bre ast by reshaping and rearrangement of the parench yma and
tightening the ptotic skin envelope. Skin only mast opexies tend to lose shape over time. Suturing the g
land itself results in a more durable shape.
Periareolar-the new areola is circumscribed, points around the areola are connected to f orm a circle or
oval pattern that is larger in diameter than the original areola; skin between the inner and outer diameters
is de-epithelialized. The amount of lift obtaine d is limited to 1–2 cm.
Vertical- a vertical or oblique limb is added to the periareolar scar; can be used to correct all grades of
ptosis; improve projection and upper pole fullness, and maintain a long-lasting shape.
Inverted T- consists of periareolar, verti cal, and horizontal components; longer scars, botto ming out;
diminishes skin pleating and dogears.

IMAGING IN SURGERY
-Dr. Amit Gupta

Radiologic imaging is an integral compo nent in the management of surgical patients. Imaging is utilized
in the diagnosis treatment and post treatment surveillance. One must be familiar with the available
imaging modalities and understand the appropriate utiliza tion and limitations of each, which often varies
based on the study indication.

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In particular, a general sense of the sensitivity, specificity, and positive and negative pre dictive values of
an imaging study helps the clinician assimilate and interpret imaging information that can be misleading
or even contradictory.

Radiography
Conventional radiography creates a two-dimensional gray-scale image produced by the diff erential
attenuation of x-rays that pass through soft tissue s of varying density. Tissues that are very dense, such as
bone, will absorb more x-rays than tissues that ar e less dense, such as lung. Radiographs are ther efore best
suited to detect pathology when a lesion differs reatly in density from adjacent structures, such as a soft
tissue mass surrounded by aerated lung or a lytic l esion surrounded by dense bone. Radiographs have
excellent spatial resolution: the ability to detect a small o bject within a given volume. However, they are sub
optimal when there are only subtle differences in tissue den sity. Therefore, even large lesions can be missed i f
they are of similar density to surrounding structures. Give n this and other limitations, additional imaging m
odalities are often obtained to supplement plain radiographs.

Fig: 1 Plain X-Ray Abdo men showing free gas under right dome of diaphragm

Intravenous Urography
Intravenous excretory urography (IVU) has been a mainstay of urologic imaging for several years. The
indications for performing an IVU are numerous. IVU allows imaging of the renal pare nchyma, collecting
system, and ureter. It can be used in the evaluation of urothelial abnormalities in evaluation of
haematuria or in the evaluation of urolithiasis. As a parenchymal imaging technique, it may detect gross
abn ormalities, but it has been superseded by cross-sectional imaging methods.(Fig:2)
Loopography
Loopography generally implies imaging of a urinary conduit or diversion.
The most common urinary diversion is the ileal conduit, but any bowel
segment may be used. Additionally, complex continent diversions and
neobladders may also require imaging, and the urologist and radiologist
should be familiar with the details of the surgical reconstruction.
Cystourethrography
Cystourethrography is performed for evaluation of pathology in the
lower urinary tract. The three major stu dies that may be performed
are static cystography, voiding cystour ethrography, and
retrograde urethrography. The examinations pote ntially allow
evaluation of both anatomic defects and functional anomalies.
Fig: 2 Urogram shows distention
of the collectin g systems from
ureteral compre ssion
Retrograde Pyelography
The retrograde pyelogram (RP) is an oft en-used study to evaluate the renal collecting syste m and the
ureters. It is a unique study in that the operating urologist, as opposed to the radiologist, is intima tely
involved in the imaging process. The study allows superb visualization of the urothelium of the upper
urinary tract but is limited by the need for operating room facilities, anaesthesia, and expense.(Fig:3)

Fig: 3 Normal retrograde pyelogram with visualization of the pyelocalyceal sy stem and ureters

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Ultrasonography (US)
As an extension of the physical exam ination, US is a valuable adjunct to surgical pra ctice in the office,
emergency department, operating room, and surgical ICU. Once surgeons have learned the essential
principles of US, they can readily build on this e xperience and extend the use of this technology to various
specific aspects of surgery.US is an imaging m odality utilizing pulse-echo techniques rather than radiation to
produce an image US-directed biopsy of breast lesions is now a common office procedure for surgeons.
Indicationsfor breast US include evaluation of non palpable lumps or microcacifications detected on
mammography, differentiate between solid and cystic ma ss and biopsy from a deep seated breast lump.
Endoscopic US (EUS) and endorectal US have added a new dimension to the preoperati ve assessment
and treatment of many gastrointestinal lesi ons. EUS has been used to facilitate FNA for biopsy of
submucosal lesions of the gastrointestinal tract, as w ell as lesions of the pancreas.
Duplex Ultrasound is now the most commonly performed test for the detection of infrainguinal DVT, both
above and below the knee, with sensitivity and specificity greater than 95% in symptomatic patient s. 3 DUS
combines real-time B-mode ultrasound with pulsed Doppler capability. Color flow imaging is useful in more
technically difficult examinations such as in the evaluation of possible calf vein DVT. Focused assessment of
the sonographic examination of the trauma patient (FAST) is a rapid diagnostic examination to assess patients
with potential thoracoabdominal injuries.(Fig:4) FAST is designed to assess fluid accumulation (presumed to
be blood) in dependent areas of the pericardial sac and abdomen while the patient is in the sup ine position.

Fig: 4 Transducer positions for FAST: pericardial, right upper quadrant, left upper qu adrant, and pelvis

Contrast Radiography of the Upper G astrointestinal Tract

A contrast medium, usually a radiocontrast agent such as barium sulfate mixed with wa ter, is ingested or instilled
into the gastrointestinal tract, an d X-rays are used to create radiographs of the regions of interest. The barium
enhances the visibility of the rel evant parts of the gastrointestinal tract by coating th e inside wall of the tract and
appearing white on the film. Th is in combination with other plain radiographs allows for the imaging of
parts of the upper gastrointestinal tract such as the pharynx, larynx, oesophagus, s tomach, and small
intestine such that the inside wall lini ng, size, shape, contour, and patency are visibl e to the examiner.
With fluoroscopy, it is also possible to visualize the functional movement of exam ined organs such
as swallowing, peristalsis, or sphincter closure. Depending on the organs to be examined, barium
radiographs can be classified into barium swallow, barium meal, barium follow-through, and enteroc
lysis (small bowel enema). (Fig: 5, 6)

Fig: 5 Well defined mucosal Fi g: 6 Enteroclysis in double Fig: 7 Barium e nema

lesion seen in mid oesophagus co ntrast technique showing demonstrating “apple core” or
st enosis of the small intestine “napkin ring” l esion, caused
by a constricting carcinoma

Computed Tomography
CT generates cross-sectional images from the transmission of radiation through tissue. A patient lies on the
scanner table within a gantry that houses an x-ray generator opposite multiple rows of detectors, hence the
term multidetector CT (MDCT).Current generation scanners (e.g., 64 or 128 MDCT) are a ble to acquire high-
resolution image data much faster due t improvements in the number of detectors and computer processing.
161
Both intravenous (IV) and oral contrast agents may be utilized to improve spatial resol ution. Oral contrast
agents are routinely used for abdominal and pelvic imaging to distinguish bowel from adjacent organs, lymph
nodes, and tumors (Fig: 8) The use of an intravascular contrast agent during CT depends on the study
indication, target organ, and patient s tatus. IV contrast agents contain variable conce ntrations of iodine
compounds that attenuate, or absorb, x-rays, which allows for enhanced detection of vascular structures.
Administration of IV contrast media is required for thorough assessment of vessels (e.g., aorta, pulmonary
arteries), solid organs (e.g., liver, kidney s), and characterization of lesion vascularity.

Fig: 8 Axial computed tomography image demonstrating an adenocarcinoma of the pancreatic head
with tumor abutting the superior mesenteric artery

Magnetic Resonance Imaging

MRI generates cross-sectional images without ionizing radiation. MRI utilizes strong magn ets, typically 1.5 or
3.0 T for clinical applications. Although the inherent tissue contrast with MRI is excellent, t he administration of
contrast media can further improve the detection of pathology and subtle differences in tis sue properties. One
of the advantages of MRI over CT is that it can provide functional in addition to anatomic information. MRI
accurately delineates muscle groups an d distinguishes among bone, vascular structures, and tumor. Sagittal
and coronal views allow evaluation of anatomic compartments in three dimensions. M agnetic resonance
cholangio-pancreatography (MRCP) is a medical imaging technique that uses magnetic re sonance imaging to
visualize the biliary and pancreatic duct s in a non-invasive manner. This procedure can be used to determine
if gallstones are lodged in any of the ducts surrounding the gallbladder.(fig: 9)

Fig: 9 Coronal maximum intensity pro jection of a gadolinium-enhanced magnetic resoonance angiogram
demonstrates thrombus as a signal void (T) within the lumen of the main portal vein (PV) and the
proximal right portal vein

Endoscopic retrograde cholangiopancreatography (ERCP)

It is a minimally invasive procedure that involves passing an endoscope into the duodenum and
cannulating the main bile duct at the ampulla of Vater. Contrast is then infused to image both the biliary
an d pancreatic ductal system. In addition to being minimally invasive, ERCP carries risks associated
with consciou s sedation and can induce pancreatitis in 1.3% to 8.6% of p tients.

Percutaneous Transhepatic Cholangi ography (PTC)

An intrahepatic bile duct is accessed percutaneously with a small needle under fluoroscopic guidance. Once the
position in a bile duct has been confirme d, a guidewire is passed and subsequently a catheter passed over the wire.
Through the catheter, a cholangio gram can be performed and therapeutic intervent ions done, such as biliary drain
insertions and stent placem nts. Percutaneous transhepatic cholangiography (PTC) has little role in the management
of patients with uncomplicated gallstone disease, but is particularly useful in patients with bile duct strictures and
tumors, as it defines the anatomy of the biliary tree proximal to the affecte d segment.
Nuclear Imaging
Although radiographic and cross-section al studies provide important anatomic information r egarding
pathologic processes, nuclear radiology provides physiologic information based on the distribution of
an injected or ingested radiopharmaceutical. Radiop harmaceuticals consist of a radioactive substrate
(radionuclide, radioisotope, or radiotracer) that is coup led with a physiologically active compound or
analogue. For example, technetium-99 m is a radioisotope that is coupled to pertechnetate, an iodine
analogue, whi ch can enter thyroid follicular cells.
162
The timing of imaging depends on the kinetics of absorption, metabolism, and half-life of the
radionuclide. Gamma rays emitted by nuclear decay o f the radionuclide are then detected using a γ-
camera corresponding to radiotracer activity that is described in terms of uptake.
Iodine Imaging
Both iodine-123 (123I) and iodine -131 (131I) are used to image the thyroid gland. The former emits
low-dose radiation, has a half-life of 12 to 14 hours, and is used to image lingual th yroids or
goitres. In contrast, 131I use leads to higher-dose radiation exposure and has a half-life of 8 to 10
days. Therefore, this isotope is used to screen and treat patients with differentiated thyroid
cancers for metastatic disease.(fig: 10)

Fig: 10 Radioactive iodine s can of the thyroid with the arrow showing an ar ea
of decreased uptake, a cold nodule
99mTechnetium-labeled sestam ibi scan
It is the most widely used and accurate modality, with a sensitivity greater than 80% for detection
of parathyroid adenomas. 68 Sestamibi, also known as Cardiolite, was initially intr oduced for
cardiac imaging and is concentrated in mitochondria-rich tissue. It was subsequently noted to be
useful for parathyroid localization becau se of the delayed washout of the radionuclide from
hypercellular parathyroid tissue when compared to thyroid tissue. Sestamibi scans are generall y
complemented by neck ultrasound which can identify adenomas with greater than 75% sensitivity
in experienced centres, and is most useful in identifying intrathyroidal parathyroids.
Biliary Radionuclide Scanning (HIDA Scan)
Biliary scintigraphy provides a non-invasive evaluation of the liver, gallbladde r, bile ducts, and
duodenum with both anatomi c and functional information. 99m-Technetium-lab eled derivatives of
dimethyl iminodiacetic acid (HID A) are injected intravenously, cleared by the Kupff er cells in the liver,
and excreted in the bile. Uptake by the liver is detected within 10 minutes, and the gallbladder, the bile
ducts, and the duodenum are vi sualized within 60 minutes in fasting subjects. The primary use of
biliary scintigraphy is in the diagnosis of acute cholecystitis, which appears as a nonvisualized
gallbladder, with prompt filling of the commo n bile duct and duodenum. Evidence of cystic duct
obstruction on biliary scintigraphy is highly diagnostic for acute cholecystitis
Positron Emission Tomograp y
PET-CT has become the preferr ed imaging modality for clinical staging, facilitating the
characterization of benign versus malignant path ology, detecting sites of unsuspected disease,
iden tifying optimal sites for tissue sampling, assessin g treatment response, and monitoring for
recurrrence for multiple malignancies.PET-CT combines the physiologic assessment of PET with
the anato mic assessment of CT, resulting in improved diagno stic accuracy.(fig:11 a,b,c)

Fig: 11(a) PET (b) CT scan (c) PET CT fused images

Conclusion
Imaging is definitely an integral part of surgery but one should not forget that it cannot re placea good
history taking and clinical examination which is a time tested method for arriving at a diagnosis.
Therefore imaging should be used judiciously in patient ma nagement.
163
References:
F. Charles Brunicardi , Dana K. Andersen , Timothy R. Billiar , David L. Dunn , John G. Hunter.Schwartz's Principles of
Surgery 2010
Edward C. Halperin , Luther W. Brady , Carlos A. Perez , David E. Wazer. Perez & Brady's Principles And Practice Of
Radiation Oncology 6th Edition 2013
Lee HJ, Choi BI, Han JK, et al: Three-dimensional ultrasonography using the minimum transparent mode in obstructive biliary
diseases: Early experience. J Ultrasound Med 21:443, 2002
Ralls PW, Jeffrey RB Jr., Kane RA, et al: Ultrasonography. Gastroenterol Clin North Am 31:801, 2002
Wexler RS, Greene GS, Scott M: Left hepatic and common hepatic ductal bile leaks demonstrated by Tc-99m HIDA scan
and percutaneous transhepatic cholangiogram. Clin Nucl Med 19:59, 1994
Magnuson TH, Bender JS, Duncan MD, et al: Utility of magnetic resonance cholangiography in the evaluation of biliary
obstruction. J Am Coll Surg 189:63, 1999
Washington M, Ghazi A: Complications of ERCP, in Scott-Conner CEH (ed): The SAGES Manual. New York: Springer-
Verlag, 1999, p 516

NO SCALPEL VASECTOMY
-Dr.R.C.M.Kaza, Dr. Lovenish Bains, Rajesh Arora

No Scalpel vasectomy is the gold standard of male sterilization. It is a refined method of vasectomy,
first developed by Dr. Li Shun Qiang of China in 1974. It is a minimally invasive approach to vas
without any formal incision or a stitch; done under local anesthesia. Male sterilization forms 1.1% of
all sterilizations in the country. Global scenario is also roughly the same with male sterilization
accounting for 2.5% of all sterilization. Clearly a major effort has to be made to rope in men.
Men have only too contraceptive methods. One is condoms, which is temporary and other vasectomy which is
permanent. Vasectomy is a simple, safe, effective and inexpensive surgical procedure that permanently ends a
man's fertility. Vasectomy involves excision of a segment of vas deferens and ligating the cut ends thereby
preventing discharge of sperms during each ejaculation into the male urethra. Vasectomy has been used for
permanent male sterilization since the late 19th century. It is the only long-term contraceptive method available to
men. As such, it affords man an opportunity to shoulder the responsibility of contraception.
NSV was introduced in India in 1992. It was formally made into a national programme in 1997. A
massive training campaign was coupled with this launch of NSV. Author has personally trained over
4000 surgeons in NSV. There is a formal system of training for trainers and service providers.
NSV with fascial interposition is gold standard for male sterilization. There is no formal incision and a stitch
in NSV and this allays the fears of men about wound related complications and leads to greater acceptance
of the procedure; while fascial interposition prevents spontaneous re-canalization and failure.
There are many recent developments in NSV both in anesthetic technique and occlusive technique. There is the
use of Jet injector for administration of local anesthesia. Methods of occlusion of vas also have evolved.
Increasingly thermal cautery and titanium clips are replacing traditional silk suture for occlusion. Excision of a
segment of vas deferens that has been the hall mark of all forms of vasectomy has also been questioned in a new
procedure, the Inline vasectomy. Studies indicate that use of thermal cautery to cauterize a split open segment of
vas without excising the segment is equally effective in producing azoospermia.
Spontaneous re-canalization of vas has also followed the vasectomy, both in human beings and in
animal experiments. In the follow up studies of Phadke and Walker (1958), natural reunion was
observed in some cases. Reversal of vasectomy can also be done for therapeutic reasons. 1-2% of
men regret their decision for vasectomy. Micro surgical reversal of vasectomy is the current standard
and assures 92% sperm positivity and up to 70% pregnancy after surgery. Pregnancy being a couple
dependent phenomenon occurs in only 65% - 70% of cases.

APPROACHES TO VASECTOMY
There are two methods of approaching vas. TheIncisional/Conventional Vasectomy and Non-scalpel
Vasectomy. Regardless of the method of scrotal entry, the first step in the vasectomy is to identify and
immobilize the vas through the skin of the scrotum and make it subcutaneous. The second step is to
exteriorize the vas by either an Incision or by the No Scalpel approach.

Conventional Vasectomy
In the conventional vasectomy, bilateral or single midline incision is made with a scalpel in the scrotal skin,
each usually 1-2 cm long and overlying the vas deferens. Jhaver (1958) developed a single midline incision,
single stitch method of performing conventional vasectomy thereby proving that bilateral vasectomy can be
performed through one incision. The incision is closed with sutures after the vasectomy has been
completed. In general, with conventional vasectomy, only the area around the skin entry site is anesthetized
and vasal block, if attempted, is a blind injection at the root of scrotum into the chord.

164
No-scalpel Vasectomy
No scalpel vasectomy (also known as NSV), is a unique method of gaining access to vas deferens for
vasectomy. NSV was conceived by Dr. Li in china in 1972 and at that time vasectomy was unpopular
with Chinese men, and tubal occlusion was the predominant method of voluntary sterilization.
Today in Sichuan province, where Dr. Li worked; vasectomy outnumbers tubal occlusion by a ratio of four to one.
In the rest of China, tubal occlusion outnumbers vasectomy by five to one. More than 10 million Chinese men have
already undergone no-scalpel vasectomy. NSV utilizes two specialized instruments - a ringed clamp and a
dissecting forceps (a sharp, curved modified hemostat) are used. The dissecting forceps is used to make a small
skin puncture to access and exteriorize the vas. Scrotal skin puncture made with the dissecting forceps is so
small that scrotal skin closure with a stitch is not required. No-scalpel vasectomy offers several advantages over
conventional vasectomy: fewer complications, less pain during the procedure and leaves a smaller wound than
conventional techniques, and earlier resumption of sexual activity after surgery.
Because it requires no scrotal incision and eliminates the scalpel, no scalpel vasectomy is believed to decrease
men's fears about vasectomy. Neither conventional nor no-scalpel vasectomy is time-consuming, but it has been
reported that the vasectomy procedure time is shorter when skilled providers use the no-scalpel approach. On the
other hand, others believe that NSV does not reduce the risk of surgical complications over the standard
incisional approach to expose the vas. The point was however settled by an RCT done at Kings Birthday
vasectomy festival in Thailand in 1982 where two teams of expert surgeons performed both conventional
vasectomy and NSV. It was proved that NSV takes less time and has fewer complications.

Anesthesia in vasectomy
Anesthesia technique in vasectomy is critical to its acceptance. Almost all vasectomies are performed
under local anesthesia. General anesthesia may be used because of the fear of pain on the part of
client. Many vasectomists use multiple blind injections with local anesthetic into the spermatic chord.
This may result in hematomas and injury to the testicular vessels. One study in animals suggested
that such blind injections may result in injury to the testicular artery with subsequent testicular
atrophy in up to 5% of the cases, despite the use of a fine-gauge needle. Spermatic chord block at the
level of pubic tubercle has previously been proposed for scrotal surgery. However, it is difficult to
isolate the vas deference from internal spermatic vessels in the region of pubic tubercle.

External spermatic sheath injection for vasal nerve block has been used in over 10 million vasectomies in China.
The vas deferens is surrounded by three layers. The external and internal spermatic fascial layer with an
intervening cremasteric layer which is also called cremasteric fascia. This layer has bundles of cremasteric
musculature separated by loose areolar tissue. This is an ideal layer to place the local anesthetic.
The technique, which involves a deep injection alongside the vas, creates a vassal block. Conventional
techniques anesthetize only the area around the skin-entry site. Injection of the anesthetic away from the
vasectomy site in the direction of the inguinal ring helps painless handling of vas. Care is taken when
injecting the lignocaine to keep the needle away from the internal spermatic fascia that encloses the
testicular artery and veins. Because the surgeon makes only a single needle puncture and one smooth
injection for each vas, the risk of bleeding and chord hematoma is reduced. In a randomized trial comparing
no-scalpel vasectomy to the conventional technique, men undergoing no-scalpel vasectomy with vasal
block anesthesia reported experiencing less operative pain than did men undergoing conventional
vasectomy (Sokal et al., 1999).18 Philip Li et al described the technique of external spermatic sheath
injection for vasal nerve block in over 500 patients in United States in 1992. They did not detect any
complication attributable to this technique. External spermatic sheath injection for vasal nerve block into
the chord is now the most common method used for local anesthesia in NSV.

Jet injector is a nearly painless, rapid, needle-free method of drug administration. It has previously been
used to administer vaccination to more than a billion people worldwide. Jet injector has evolved as an
instrument that could allow needle free, virtually painless anesthesia for most primary care procedures. The
physiological advantages of the jet injection is that it can provide effective anesthesia using small volume
of local anesthetic of at least 2% concentration, with minimal patient discomfort compared to conventional
needle and when used the patient is totally unaware of the experience both of injection and the procedure
that follows. Another advantage of jet injection technique is that a very small amount by volume (0.1 cc of
2% anesthetic) will provide unusually high levels of tissue anesthesia.
Another Recent development is Mini needle Anesthesia where a 30G needle is used to administer
anesthetic directly into the vas of both sides. This is claimed to be as painless and equally effective as
Jet injector. It is also much cheaper and avoids expensive equipment.

OCCLUSION TECHNIQUES
Once the vas has been brought into the open, it is then occluded using a variety of methods. The
same tech-niques are used to occlude the vas in both conventional and no-scalpel vasectomy.
Although there are few complications associated with vasectomies, sometimes problems arise and
the method of vas occlusion is sometimes the cause. At least 28 occlusive methods have been
described over the years. Different techniques for occlusion are:
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 Ligation & excision
Ligation & excision with fascial i
nterposition Electro-cautery
Thermal
cautery Clips
Combination of different methods
Open ended vasectomy
Inline vas occlusion
Simple ligation and excision: It is th e most common method being used in developing countries
including India. This is very simple, most practical and inexpensive method of occlusion. It involves tyi
ng the vas deferens with suture material, cutting it, and in many cases, removing a section of the vas.
Fascial Interposition: In this technique fascia is interposed between two cut ends of vas. T his is done by
tying (or securing with clip) the thin layer of ti ssue that surrounds the vas (internal spermatic fasc ia)
over one end of vas.
Electro-cautery: In this method using m inimum of electric power two cut ends of vas are s ealed with the help
of electro-cautery. This method has limitations in that when the more common monopolar electrosurgical unit
is used for fulguration, tissue destruction m ay be inadequate; on the contrary, it may be so ex tensive that the
end of vas sloughs, thus allowing leakage of sperms and formation of granuloma. Unfortunately, bipolar
needle which precisely regulates the amount of current is not commonly available.
Thermal cautery: Thermal cautery is a highly effective and safe method to occlude the vas for vasectomy.
With this method, only the inner layer of th e vas is sealed closed; the muscle wall of the va s remains
intact. A segment of the vas is removed as well.
Metal clips: Clips are also being used by some vasectomists, which are applied to open end of vasal
stump. Questions have been raised about the use of clips concerning the practicality and cost o f
procedure in less developed countries.
Open ended vasectomy: In this method testicular end of vas is not ligated. Although it has been tried, it is not
commonly used. Data have shown that this technique causes less pressure-induced damag e to the epididymis
and reduces incidence of granuloma for mation in epididymis. Thus, it is possible that vasect omy reversal will
be more successful following an open-ende d vasectomy. However, no studies on open-ended vasectomy and
the success of reversal efforts have been r eported in the literature. Overall results from available studies
suggest that the open ended, technique is not as sociated with increase in vasectomy failure risk wh en the
prostatic end is adequately closed by means of fascial Interposition and cautery.
Inline Method of Vas Occlusion: In this method neither any scalpel, nor any suture is used. Furthermore
mesentery of vas is not touched and no portion of vas is removed. This method is rapid an d can be performed
with NSV instruments but in addition requires a fine skin hook, a short bladed fine scissors and a hand held
thermal cautery. It utilizes luminal cautery, detubularization of vas and fascial disruption. V as lumen is opened
on abdominal and testicular side at a di stance of one centimeter, cauterized on both abdominal and testicular
sides. Intervening portion of vas is de ubularized and edges are trimmed to prevent re- tubularization. This
method seems to produce fewer incidences of hematoma, granuloma and failure rates.
Research in contraception is on to develop reversible methods of intravasal contrraception such as
RISUG which is intravasal contraception with use of styrene Malleic anhydride. Currently Phase 3 trials
are on.

166
167
 R. C. M. Kaza, “No scalpel vasectomy—an overview,” Journal of the Indian Medical Association , vol. 104, no. 3, pp.
129–141, 2006.

EFFECTIVENESS
Vasectomy is one of the safest and most effective methods of permanent contraception. But it has the
disadvantage that it is not immediately effective because viable sperms have to be cleared from the vas distal to
vas occlusion. The success of the procedure is confirmed by absence of sperms in the semen sample obtained
after vasectomy. Thus, the vasectomy user and his spouse must practice alternative methods of contraception for
some time after the procedure. Only 75% men are azoospermic after 3 months. Early and late failures are
observed. Nature of vas occlusion techniques also impacts on early azoospermia as well as failures. Ligation and
excision has the highest failures rates. Addition of Facial Interposition (FI) not only reduces failures but results in
early azoospermia. Thermal cautery occlusion has the lowest failure rates.
A number of reports have shown that men with low numbers of non-motile sperm remaining after
vasectomy are at low risk of causing pregnancy. Some have suggested that these men can rely on their
vasectomy for contraception even before reaching azoospermia. However, Endpoints of vasectomy other
than azoospermia have not been widely accepted. According to the standards for Male& Female Sterilization
set by Ministry of Health and Family Welfare, Government of India the client should undergo semen analysis
after three months. However, in the best of situations and after good counseling, men do not return for
follow up even in US and Europe. Best follow up rates do not cross 45%.

COMPLICATIONS
Intraoperative complications of vasectomy, such as vasovagal reaction, lidocaine toxicity, and excessive bleeding,
are unusual. Explaining the procedure to the client in advance, ensuring an effective anesthetic block, using
gentle surgical technique, and reassuring the client during the procedure can prevent vasovagal reaction.
Lidocaine toxicity and excessive bleeding can be prevented if providers follow appropriate vasectomy guidelines
and procedures for administering local anesthesia and for the surgical technique.
Most postoperative vasectomy complications are minor, subsiding within 1-2 weeks. Common complaints
after surgery are swelling of the scrotum, bruising, and pain. Minor bleeding under the skin is common.
Some men experience tenderness or a dragging sensation in the scrotum for up to a week after vasectomy.
A scrotal support, mild pain medication, and local application of ice are usually sufficient treatment.
More significant complications such as heavy bleeding, hematoma (a collection of blood underneath
the skin) or infection are generally quite rare.
168
The incidence of hematoma is related to the provider's experience with vasectomy: Physicians who perform larger
numbers of vasectomies have lower hematoma rates than do those who perform fewer procedures. Importantly,
rates of heavy bleeding, hematoma, and infection vary depending on the approach taken to the vas. Numerous
studies have demonstrated that the no-scalpel approach consistently results in lower rates of hematoma and
infection than does conventional vasectomy. In most cases, using good surgical technique to minimize tissue
trauma and limit bleeding, practicing aseptic technique, and giving clients good postoperative instructions can
prevent bleeding, hematoma, and infection. Because the loose scrotal tissue allows injured blood vessels to
continue bleeding, it is important to maintain good homeostasis during the procedure if hematoma formation is to
be prevented. Many Hematomas can be prevented if men avoid physical activity for a few days after the procedure;
clients should be carefully instructed in this regard.
Sperm granuloma can occur either at the site of vas occlusion or in the epididymis. These small
nodules form when sperm leak out of the vas or the epididymis, inducing an inflammatory reaction.
While the true incidence of sperm granuloma following vasectomy is not known, they are seen in 15-
40% of men having vasectomy reversal. This provides a reasonable estimate for incidence in men
following vasectomy, in that rates of granuloma formation are likely to be similar in men having a
reversal and in the general population of vasectomized men.
The majority of sperm granuloma is asymptomatic. Only 2-3% of vasectomized men have sperm
granuloma that is painful or in some way symptomatic; most of these occur in the second or third
week after the procedure. The factors that lead to the formation of sperm granuloma are not well
understood; thus, there are no measures known to prevent or decrease their occurrence.
Table - 1: Percentage of vasectomies in which infection or hematoma or bleeding
occurred, by type of vasectomy and study:
Study No. Of Vasectomies % With infections % With hematoma/
bleeding
Incisional vasectomy
Philp, Guillebaud, & Budd, 1984 534 1.3 4.5

Kendrick et al, 198731 65.155 3.5 2.0

Nirapathpongorn, Huber, & Krieger, 523 1.3 1.7
199019
Alderman, 199125 1,224 4.0 0.3
Sokal et al, 199918 627 1.3 10.7
No-scalpel vasectomy
Nirapathpongporn, Huber, & Krieger, 680 0.2 0.3
199019
Li et al, 199115 179,741 0.9 0.1
Li et al, 199115 238 0.0 0.0
Sokal et al, 200328 841 1.4 0.48
(In both the groups, Fascial
interposition and non interposition)
Sokal et al, 199918 606 0.2 1.7
Arellano et al, 199794 1,000 0.0 2.1

LONG- TERM EFFECTS

Potential physiological effects and long-term sequelae of vasectomy have been the subject of extensive
research over the past two decades. This research provides reassurance that vasectomy does not have any
significant long-term negative physical or mental health effects. Results of large-scale, well-designed
epidemiological studies in men have consistently shown no adverse effects of vasectomy in terms of heart
dis-ease, testicular or prostate cancer, immune complex disorders, and a host of other conditions.
Vasectomy appears to be a largely safe and highly effective method of contraception, certainly with risks no
greater than those for any of the contraceptive methods used by women.
COMPREHENSIVE STUDIES OF DISEASE INCIDENCE
There are five large-scale retrospective cohort studies that have examined the incidence of a number
of diseases in thousands of vasectomized and non-vasectomized men. For the disease categories or
organ sys-tems studied, vasectomized men were no more likely to be hospitalized or to develop a
disease than were controls. In these studies, there were large numbers of cases of disease among
both vasectomized and non-vasectomized men in all categories. Thus, taken together, the studies are
reassuring that vasectomy does not increase the risk of adverse physical or mental health outcomes.
ANTISPERM ANTIBODIES
The number of circulating antisperm antibodies increases after vasectomy: Antisperm antibodies are
found in 50-80% of vasectomized men but in only 8-21 % of men in the general population. The
theoretical concern that these antibodies may have adverse health consequences has led to
numerous studies, the results of which have shown no evidence of any immunological or other
diseases related to the formation of antisperm antibodies after vasectomy. However, antisperm
antibodies may play a role in decreased fertility after vasectomy reversal.

169
PROSTATE CANCER
Since the mid-1980s, more than a dozen epidemiological studies of the risk of prostate cancer after vasectomy
have been reported in the literature. Results have been difficult to interpret because of conflicting study findings,
lack of a convincing biological mechanism for an association between vasectomy and prostate cancer, and
generally weak associations when they have been found. Also, the potential for bias in some studies was high and
likely led to an overestimation of any effect.Based on the results of the research published to date, there is little
evidence for a causal association between vasectomy and prostate cancer. A panel of experts gathered by the U.S.
National Institutes of Health in 1993 concluded that no change in the current practice of vasectomy was necessary
nor should vasectomy reversal be done as a measure to prevent prostate cancer. 48Studies pub-lished after the
expert panel report support these conclusions.

POSTVASECTOMY PAIN SYNDROME

A small percentage of vasectomized men have reported chronic pain in the testis following vasectomy. While up to
one-third of men have reported occasional testicular discomfort following vasectomy, only around 2% of all
vasectomized men said that the pain had negatively affected their life or that they regretted having had the
vasectomy because of chronic pain.51-52 Conservative therapy such as non-steroidal anti-inflammatory drugs, sitz
baths, antibiotics, or spermatic cord blocks is sufficient treatment in most cases. When this fails, there is some
evidence that vasectomy reversal or denervation of the spermatic cord may be helpful.
MORTALITY
Mortality following vasectomy has generally been very low. The few reports from the literature have
demonstrated minimal mortality associated with vasectomy. The most comprehensive study, based
on data from more than 400,000 vasectomies worldwide, reported a mortality rate of 0.5 deaths per
100,000 vasectomized men.

VASECTOMY REGRET AND REVERSAL

REGRET
Regret following a vasectomy is more common among men who at the time of the vasectomy were in
an unstable marriage, were younger than 31, or had no children or had very young children, or among
men who made the decision to have a vasectomy during a time of financial crisis or for reasons
related to a pregnancy. Providers should use risk factors for regret to identify men who may need
more in-depth counseling to ensure that vasectomy is right for them at the time, but not to deny
vasectomy to men who want it. In addition, the fact that regret is often seen when vasectomy users
have an adverse health effect that is either caused by the procedure or perceived to be caused by it
underscores the importance of good counseling prior to the procedure

REVERSAL
The most common reasons for reversal requests are remarriage after divorce or after the death of a partner,
the death of one or more children, a desire for more children, or problems of either a physiological or
psychological nature that the vasectomized man or his provider believe will be alleviated by vasectomy
reversal.Vasovasostomy (reattaching the cut ends of the vas) is the most common procedure for reversing
a vasectomy. In some situations, it may be necessary to attach the vas directly to the epididymis; this
procedure is known as vasoepididymostomy. Both procedures are complex, technically demanding, and
expensive; most importantly, there is no guarantee that fertility can be restored. This highlights the
importance of carefully screening, counseling, and selecting vasectomy users.
Both macroscopic and microsurgical techniques for vasovasostomy and vasoepididymostomy have been used for
vasectomy reversal; the current consensus is that microsurgical techniques are more successful. Reported rates
of patency (evaluated by the presence of sperm in the ejaculate) following vasovasostomy range from 74% to 92%
for macroscopic reversal and from 75% to 100% for microsurgical reversal. Reported pregnancy
rates are lower, however, ranging from 35% to 57% for macroscopic and from 38% to 82% for microsurgical
vasovasostomy approaches.61, 62,66,68,69 Vasoepididymostomy is generally less successful than vasovasostomy,
and while pregnancy rates as high as 42-55% have been reported. Most are lower, ranging from 10% to 30%.
Several factors affect the success of vasectomy reversal: the technical demands of the surgery itself; the type of
vasectomy procedure performed; the length of time between the vasectomy and the reversal procedure; the levels
of antisperm antibodies that may have developed after the vasectomy or the reversal; and changes in the
epididymis or partial obstruction of the vas after reversal that prevent sperm from moving through the vas.
The time that has elapsed between vasectomy and reversal is a major factor in the success of reversal: The
longer the interval between vasectomy and reversal, the less likely the man is to be fertile after reversal.
Reversal is usually more successful when it is done within 10 years of the vasectomy; pregnancy rates drop
to less than 50% when vasectomy reversal is performed more than 9-10 years later.
Reports of the effect of antisperm antibodies on fertility following vasectomy reversal vary; some studies
have shown decreased pregnancy rates due to antisperm antibodies, while others have not. The consensus
is that fertility following vasectomy reversal is inhibited only by high levels of antisperm antibodies.
Partial obstruction of the vas after vasectomy reversal (e.g., because of a sperm granuloma or
adhesions from the surgery) has been shown to affect the success of reversal.
170
In these cases, semen quality may be poor in terms of sperm numbers, sperm motility, or both. When
partial obstruction is the cause for failure of reversal, repeat vasectomy reversal has produced good
pregnancy results.
Assisted reproduction technologies have been successful in vasectomized men who want children
but who either do not want to attempt a vasectomy reversal or have had one or more unsuccessful
reversal surgeries. Sperm can be retrieved from the epididymis or testis and then used in a procedure
known as intracytoplasmic sperm injection (ICSI), in which sperm are injected directly into the ova in a
laboratory. Pregnancy rates following ICSI with epididymal sperm are reported to be between 25% and
36%. Pregnancy rates ranging from 17% to 36% have been reported when testicular-sperm are used.
Research continues on methods of vasectomy reversal that produce better success rates.
Additionally, new assisted reproduction techniques are also being explored that might be applied in
the cases of vasectomized men who are interested in having children. However, there is no guarantee
that pregnancy will occur following vasectomy reversal or use of assisted reproduction techniques,
and these procedures are expensive and not widely available-especially in low-resource settings.
Thus, vasectomy should be considered a permanent contraceptive method.
INNOVATIONS
New methods of vas occlusion are unlikely to become available in the near future, but investigators
have explored several alternatives to surgical sterilization in men. Experimental methods of occluding
the vas include injecting chemicals into the vas percutaneously (through the skin), to scar the vas
closed or physically block the passage of sperm through the vas.
Studies on occluding the vas for contraceptive purposes by injecting chemicals percutaneously
began in the 1970s in China. This technique was easily performed and led to high rates of
azoospermia and low pregnancy rates, although reversal was no easier than for vasectomy because
the occluded portion of the vas needed to be excised and re-anastomosis of the vas performed.
Formed-in-place plugs use a liquid material that is injected into the vas and forms a solid plug to block the vas
lumen; such plugs have been examined as a method of vas occlusion. A formed-in-place polyurethane plug had
low rates of complications, was highly effective, and was easily reversible. However, uncertainty regarding the
safety of the polyurethane product led to an investigation of medical-grade silicone plugs. Variable rates of
success have been reported for a formed-in-place silicone plug known as Vasoc. Vasoc vas occlusion does not
appear to be suitable for use as a male contraceptive at this time. Researchers have also attempted to develop
devices that can be placed in the vas to obstruct sperm but then later can be removed or opened to allow sperm to
pass. Such devices have had several problems, however; for example, the surgery has been difficult and the
devices have not consistently stayed in place within the muscular vas.

SELECTED REFERENCES
Li, S.Q.: Vasal sterilization techniques: Teaching material for the National standard Workshop, Chongqing, People’s Republic of
China: Scientific and technical literature press, p.176, 1988.
Li SQ, et al. The no-scalpel vasectomy. Journal of Urology 1991; 145(2): 341-344.
AVSC International. 1997. No-scalpel vasectomy: An illustrated guide for surgeons. 2nd edition. New York
Sokal DC, et al. A comparative study of the no scalpel and standard incision approaches to vasectomy in 5 countries. The
Male Sterilization Investigator Team. Journal of Urology 1999; 162(5): 1621-1625.
Nirapathpongpom A, Huber DH, Krieger JN. No-scalpel vasectomy at the King's Birthday vasectomy festival. Lancet 1990;
335(8694): 894-895.
Li,P.S., Li,S.Q., Schlegel, P.N. and Goldstein, M.: External spermatic sheath injection for vasal nerve block. Urology, 39: 173,1992
Labrecque M, Dufresne C, Barone MA, St-Hilaire K.: Vasectomy surgical techniques: a systematic review. BMC Med. 2004 May
24;2:21
Joel LM, Stuart K, Victor H H. A minimal invasive vasectomy with no suture, inline method of vas occlusion. In j Fertil 2001; 46:257-

Dr. R. C. M. Kaza, “No scalpel vasectomy—an overview,” Journal of the Indian Medical Association, vol. 104, no. 3, pp. 129–141,
2006.
Sokal D, et al. (2001) Vasectomy with fascial interposition vs. ligation and excision alone: A randomized controlled trial.
Presentation at the annual meeting of the Association of Reproductive Health Professionals, December 12-15, Washington, DC.
Kendrick JS, et al. Complications of vasectomies in the United States. Journal of Family Practice 1987; 25(3): 245-248.
Healy B. From the National Institutes of Health: Does vasectomy cause prostatecancer? Journal of the American Medical
Association 1993; 269(20): 2620
Belker AM. Evaluation of partial anastomotic obstruction after vasovasostomy and predictors of success after
vasoepididymostomy. Journal of Urology 1998; 159(3): 835-836.
Silber SJ. Results of microsurgical vasoepididymostomy: Role of epididymis in spermmaturation. Human Reproduction 1989;
4(3): 298-303.
Dohle GR, et al. Surgical sperm retrieval and intracytoplasmic sperm injection as treatment of obstructive azoospermia.
Human Reproduction 1998; 13(3): 620-623.
Abuzeid ML, Sasy MA, Salem H. Testicular sperm extraction and intracytoplasmic sperm injection: A simplified method for
treatment of obstructive azoospermia. Fertility and Sterility 1997; 68(2): 328-333.
Zhao SC. Vas deferens occlusion by percutaneous injection of polyurethane elastomer plugs: Clinical experience and
reversibility. Contraception 1990; 41(5): 453--459.
Soebadi DM, Gardjito W, Meurik HJ. Intravasal injection of formed-in-place medical grade silicone rubber for vas occlusion.
International Journal of Andrology 1995; 18(Suppl. 1): 45-52.
Herrel L, Hsiao W, Microsurgical vasovasostomy, Asian Journal of Andrology 15 (1)44-8 2013
20.Grace shih, Merlin Njoya, MaryleneLessard, Michel Labrecque, MINIMIZING PAIN DURING VASECTOMY: THE MINI-NEEDLE ANESTHETIC
TECHNIQUE J.UROL183, 1959-1963, 2010.

171
 IMAGIN G OF PERIPHERAL VASCULAR DISEAS E
-D r. Rashmi Dixit

The peripheral vasculature is a common site for vascular disease. Advances in imaging tec hnology have
had a significant impact on vascular imaging, resulting in a shift from invasive to non invasive imag ing.
The modalities currently available to evaluate periphera vessels include:
Ultrasound and color Doppler flow imaging (CDFI).
CT angiography and venography
MR angiography and venography
Digital subtraction angiography

EVALUATION OF THE PERIPHERAL A RTERIAL

SYSTEM Imaging Modalities
Ultrasound and Doppler Scanning
The arteries of the upper and lower extremities are easily accessible to sonographic imaging with high
resolution transducers. Real time grey scale imaging is useful for evaluating the presence of atherosclerotic
plaque or thrombus and confirming the p resence of extravascular masses but provides no i nformation on
blood flow. Duplex and color Doppler imaging assess blood flow patterns. Power Doppler is a complementary
imaging technique, 3-5 times more color flow s nsitive than color Doppler and less angle depend ent. Power
Doppler depicts very slow flow, improves visualization of vascular borders and contours and in c ases of
stenosis it improves delineation of residual lumen. he normal spectral Doppler pattern of arterial flow in the
extremities is a high resistance wave form. The config uration of this wave form is typically triphasic indic
ating strong forward component of blood flow during systole, followed by a short reversal of flow during
diastole. A return to forward flow of lower amplitude normally follows and lasts for a variable length of
diastole. The diast olic flow is absent in vessels that have lost compliance as in therosclerosis and diabetes.

CT Angiography (CTA)
CTA is a noninvasive means of evaluating blood vessels requiring only an IV injection of c ontrast. The images
can be evaluated in 2D as well as 3D. The advent of multi detector row CT has had subst antial impact on CT
angiography offering shorter acquisition times, lower doses of contras medium, increased v olumetric
coverage and /or improved Z axis resolution with t hinner sections because of increase in scanner spee d.
Advantages of CTA over DSA include 3D-volumetric data analysis and display, smaller v olumes of
contrast material, minimal invasiveness and thus a lower complication rate, better visualisation of distal
arteries and shorter examination times. However sma ll arteries are not well visualized.

MR Angiography (MRA)
Two basic techniques are used for non contrast MRA – Time of flight (TOF) 1and Phase Co ntrast
Angiography (PCA).
Contrast MRA (CE-MRA) has substantially changed imaging strategies in patients with peripheral vascular
disease. With CE-MRA signal of flowin g blood is no longer flow dependent. Flow induced artifacts seen with
non contrast MRA techniques are therefore largely eliminated. This allows coronal coveragge of large vascular
territories in short imaging times and g enerates imaging that are similar in appearance to conventional X-ray
based catheter angiography. Metallic stents or clips however, may produce artifacts sig nificantly degrading
image quality. Resolution of smaller ves sels remains a problem.

Digital subraction angiography

Gold standard of arterial imaging
Compares a pre contrast image with a post contrast image using a computer, and "s ubtracts"
elements common to both.
– Prevents images of objects like bones etc from obscuring vascular details.
– Highest resolution
– Drawbacks
– Technique is invasive and expensive.
– Requires arterial puncture
– Longer study than CT
– Contrast nephrotoxicity
– Prior to radiological intervention

Presence or absence of significant obs truction of flow.

172
Site and anatomical extent of obstruction.
Condition of collateral flow and distal vasculature for planning
treatment. Result of therapy and disease progression.

CONCLUSION
Advances in non-invasive imaging mo modalities like Doppler sonography, CT angiography and MR
angiography have greatly reduced the role of invasive arteriography. Arteriography though invasive
allows percutaneous interventions to be performed in the same sitting and remains the gold standard
of vascular imaging.

MANAGEMENT OF PERIPHERAL VASCULAR DISEASE

-Dr Shaji Thomas

2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery
Disease.

[JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 69, NO. 11, 2017]
Class of Recommendation and Level of Evidence
CLASS (STRENGTH) OF RECOMMENDATION LEVEL (QUALITY) OF EVIDENCE
CLASS I(STRONG) Benefit >>> Risk LEVEL A
Is recommended High quality evidence from more than 1 RCT
Is indicated / useful / effective / beneficial Meta-analysis of high quality RCTs
Should be performed / administered / other One or more RCTs corroborated by high-quality
Comparative effectiveness phrases: registry studies
Treatment / strategy A is recommended /
indicated in preference to treatment B
Treatment A should be chosen over treatment B
CLASS IIa (MODERATE) Benefit >> Risk LEVEL B-R
Is reasonable (Randomised)
Can be useful / effective / beneficial Moderate quality evidence from 1 or more RCTs
Comparative effectiveness phrases: Meta-analysis of moderate quality RCTs
Treatment / strategy A is probably recommended
/ indicated in preference to treatment B
It is reasonable to choose Treatment A
over treatment B
CLASS IIb (WEAK) Benefit > Risk LEVEL B-NR
May / might be reasonable (Nonrandomised)
May / might be considered Moderate quality evidence from 1 or more well-
Usefulness / effectiveness is unknown / unclear / designed, well-executed nonrandomised studies,
uncertain or not well established observational studies, or registry studies
Meta-analysis of such studies
CLASS III: No Benefit (MODERATE) Benefit = Risk LEVEL C-LD
Is not recommended (Limited data)
Is not indicated / useful / effective / beneficial Randomised or nonrandomised observational or
Should not be performed / administered / other registry studies with limitations of design or execution
Meta-analysis of such studies
Physiological or mechanistic studies in human
subjects
CLASS III: Harm (STRONG) Risk > Benefit LEVEL C-EO (Expert opinion)
Potentially harmful Consensus of expert opinion based on clinical experience
Causes harm
Associated with excess morbidity / mortality
Should not be performed / administered / other

Abbreviations
ABI = Ankle-brachial index LD = Limited data
ALI = Acute limb ischemia LOE = Level of Evidence
CAD = Coronary artery disease MI = myocardial infarction
CLI = critical limb ischemia NR = Nonrandomised
COR = Class of Recommendation PAD = peripheral artery disease
DAPT = dual antiplatelet therapy R = Randomised
DES = drug eluting stents RCT = randomised controlled trial
EO = Expert opinion TBI = toe-brachial index
GDMT = guideline-directed management and therapy QoL = quality of life
173
Medical Therapy for the Patient With PAD
Patients with PAD should receive a comprehensive program of GDMT, including structured exercise and lifestyle
modification, to reduce cardiovascular ischemic events and improve functional status. Smoking cessation is a
vital component of care for patients with PAD who continue to smoke. A guideline-based program of
pharmacotherapy to reduce cardiovascular ischemic events and limb-related events should be prescribed for each
patient with PAD and is customized to individual risk factors, such as whether the patient also has diabetes
mellitus. Previous studies have demonstrated that patients with PAD are less likely to receive GDMT than are
patients with other forms of cardiovascular disease, including coronary artery disease (CAD).

Antiplatelet Agents: Recommendations

Recommendations for Antiplatelet Agents
COR LOE Recommendations

AAntiplatelet therapy with aspirin alone (range 75–325 mg per day) or clopidogrel alone (75 mg per day) is
recommended to reduce MI, stroke, and vascular death in patients with symptomatic PAD.

IIa C- In asymptomatic patients with PAD (ABI ≤0.90), antiplatelet therapy is reasonable to reduce the risk of MI,
EO stroke, or vascular death.

IIb B-R In asymptomatic patients with borderline ABI (0.91–0.99), the usefulness of antiplatelet therapy to reduce the
risk of MI, stroke, or vascular death is uncertain.

IIb B-R The effectiveness of dual antiplatelet therapy (DAPT) (aspirin and clopidogrel) to reduce the risk of
cardiovascular ischemic events in patients with symptomatic PAD is not well established.

IIb C- DAPT (aspirin and clopidogrel) may be reasonable to reduce the risk of limb-related events in patients with
LD symptomatic PAD after lower extremity revascularization.

IIb B-R The overall clinical benefit of vorapaxar added to existing antiplatelet therapy in patients with symptomatic
PAD is uncertain.

Statin Agents: Recommendation

Recommendation for Statin Agents

COR LOE Recommendation

I A Treatment with a statin medication is indicated for all patients with PAD.

Antihypertensive Agents: Recommendations

Recommendations for Antihypertensive Agents

COR LOE Recommendations

AAntihypertensive therapy should be administered to patients with hypertension and PAD to reduce the risk of
MI, stroke, heart failure, and cardiovascular death.

IIa A The use of angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers can be effective to
reduce the risk of cardiovascular ischemic events in patients with PAD.

Smoking Cessation: Recommendations

Recommendations for Smoking Cessation

COR LOE Recommendations

APatients with PAD who smoke cigarettes or use other forms of tobacco should be advised at every visit to quit.
APatients with PAD who smoke cigarettes should be assisted in developing a plan for quitting that includes
pharmacotherapy (i.e., varenicline, bupropion, and/or nicotine replacement therapy) and/or referral to
a smoking cessation program.

B- Patients with PAD should avoid exposure to environmental tobacco smoke at work, at home, and in public
NR places.

174
Glycemic Control: Recommendations

Recommendations for Glycemic Control

COR LOE Recommendations

C-Management of diabetes mellitus in the patient with PAD should be coordinated between members of the
EO healthcare team.

IIa B-NR Glycemic control can be beneficial for patients with CLI to reduce limb-related outcomes.

Oral Anticoagulation: Recommendations

Recommendations for Oral Anticoagulation

COR LOE Recommendations

IIb B-R The usefulness of anticoagulation to improve patency after lower extremity autogenous vein or
prosthetic bypass is uncertain.

AAnticoagulation should not be used to reduce the risk of cardiovascular ischemic events in patients with
HarmPAD.
Cilostazol: Recommendation

Recommendation for Cilostazol

COR LOE Recommendation

ACilostazol is an effective therapy to improve symptoms and increase walking distance in patients with
claudication.

Pentoxifylline: Recommendation

Recommendation for Pentoxifylline

COR LOE Recommendation

III: No Benefit B-R Pentoxifylline is not effective for treatment of claudication.

Chelation Therapy: Recommendation

Recommendation for Chelation Therapy

COR LOE Recommendation

III: No Benefit B-R Chelation therapy (e.g., ethylenediaminetetraacetic acid) is not beneficial for treatment of claudication.

Homocysteine Lowering: Recommendation

Recommendation for Homocysteine Lowering

COR LOE Recommendation

No B-R B-complex vitamin supplementation to lower homocysteine levels for prevention of cardiovascular events
Benefit in patients with PAD is not recommended.
Influenza Vaccination: Recommendation

Recommendation for Influenza Vaccination

COR LOE Recommendation

C-EO Patients with PAD should have an annual influenza vaccination.

Structured Exercise Therapy: Recommendations
Structured exercise therapy is an important element of care for the patient with PAD.

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Recommendations for Structured Exercise Therapy
COR LOE Recommendations

AIn patients with claudication, a supervised exercise program is recommended to improve functional status
and QoL and to reduce leg symptoms.

B-R A supervised exercise program should be discussed as a treatment option for claudication before
possible revascularization.

IIa A In patients with PAD, a structured community- or home-based exercise program with behavioral change
techniques can be beneficial to improve walking ability and functional status.

IIa A In patients with claudication, alternative strategies of exercise therapy, including upper-body ergometry,
cycling, and pain-free or low-intensity walking that avoids moderate-to-maximum claudication while walking,
can be beneficial to improve walking ability and functional status.
Minimizing Tissue Loss in Patients With PAD: Recommendations

Recommendations for Minimizing Tissue Loss in Patients With PAD

COR LOE Recommendations

C-LD Patients with PAD and diabetes mellitus should be counseled about self–foot examination and healthy
foot behaviors.

I C-LD In patients with PAD, prompt diagnosis and treatment of foot infection are recommended to avoid amputation.

IIa C-LD In patients with PAD and signs of foot infection, prompt referral to an interdisciplinary care team can be
beneficial.

IIa C- It is reasonable to counsel patients with PAD without diabetes mellitus about self–foot examination and
EO healthy foot behaviors.

IIa C- Biannual foot examination by a clinician is reasonable for patients with PAD and diabetes mellitus.
EO
Revascularization for Claudication
An individualized approach to revascularization for claudication is recommended for each patient to optimize
outcome. Revascularization is but one component of care for the patient with claudication, as each patient should
have a customized care plan that also includes medical therapy, structured exercise therapy, and care to minimize
tissue loss. If a strategy of revascularization for claudication is undertaken, the revascularization strategy should
be evidence based and can include endovascular revascularization, surgery, or both.Because of the variability of
ischemic limb symptoms and impact of these symptoms on functional status and QoL, patients should be
selected for revascularization on the basis of severity of their symptoms. Factors to consider include a significant
disability as assessed by the patient, adequacy of response to medical and structured exercise therapy, status of
comorbid conditions, and a favorable risk–benefit ratio. Patient preferences and goals of care are important
considerations in the evaluation for revascularization. The revascularization strategy should have a reasonable
likelihood of providing durable relief of symptoms. A general recommendation for revascularization as a treatment
option for claudication is provided below followed by specific recommendations for endovascular and surgical
procedures if a revascularization strategy is undertaken.

Revascularization for Claudication: Recommendation

Recommendation for Revascularization for Claudication
COR LOE Recommendation

IIa A Revascularization is a reasonable treatment option for the patient with lifestyle-limiting claudication
with an inadequate response toGDMT (12,37,38,232,233).

Endovascular Revascularization for Claudication: Recommendations

Endovascular techniques to treat claudication include balloon dilation (angioplasty), stents, and
atherectomy. These techniques continue to involve and now include covered stents, drug-eluting stents
(DES), cutting balloons, and drug-coated balloons. The technique chosen for endovascular treatment is
related to lesion characteristics (e.g., anatomic location, lesion length, degree of calcification) and operator
experience. Assessment of the appropriateness of specific endovascular techniques for specific lesions for
the treatment of claudication is beyond the scope of this document.Revascularization is performed on
lesions that are deemed to be hemodynamically significant, and stenoses selected for endovascular
treatment should have a reasonable likelihood of limiting perfusion to the distal limb.

176
Stenoses of 50% to 75% diameter by angiography may not be hemodynamically significant, and
resting or provoked intravascular pressure measurements may be used to determine whether lesions
are significant. Multiple RCTs have compared endovascular procedures to various combinations of
medical treatment with or without supervised or unsupervised exercise programs. These trials have
used different endpoints and enrolled patients with anatomic disease distribution at different levels.
Recommendations for Endovascular Revascularization for Claudication
COR LOE Recommendations

AEndovascular procedures are effective as a revascularization option for patients with lifestyle-limiting
claudication and hemodynamically significant aortoiliac occlusive disease.

IIa B-R Endovascular procedures are reasonable as a revascularization option for patients with lifestyle-limiting
claudication and hemodynamically significant femoropopliteal disease.

IIb C- The usefulness of endovascular procedures as a revascularization option for patients with claudication due
LD to isolated infrapopliteal artery disease is unknown.

B- Endovascular procedures should not be performed in patients with PAD solely to prevent progression to
Harm NR CLI.
Surgical Revascularization for Claudication: Recommendations
Recommendations for Surgical Revascularization for Claudication
COR LOE Recommendations

AWhen surgical revascularization is performed, bypass to the popliteal artery with autogenous vein is
recommended in preference to prosthetic graft material.

IIa B- Surgical procedures are reasonable as a revascularization option for patients with lifestyle-limiting
NR claudication with inadequate response to GDMT, acceptable perioperative risk, and technical factors
suggesting advantages over endovascular procedures.

B-R Femoral-tibial artery bypasses with prosthetic graft material should not be used for the treatment of
Harm claudication.

B- Surgical procedures should not be performed in patients with PAD solely to prevent progression to
CLI. Harm NR

Management of CLI (critical limb ischemia)

Patients with CLI are at increased risk of amputation and major cardiovascular ischemic events. Care of the
patient with CLI includes evaluation for revascularization and wound healing therapies, with the objective to
minimize tissue loss, completely heal wounds, and preserve a functional foot. Medical therapy to prevent
cardiovascular ischemic events is also an important component of care for the patient with CLI.
Revascularization for CLI: Recommendations
Recommendation for Revascularization for CLI
COR LOE Recommendation

B-In patients with CLI, revascularization should be performed when possible to minimize tissue loss.
NR

C-An evaluation for revascularization options should be performed by an interdisciplinary care team before
EO amputation in the patient with CLI.

Endovascular Revascularization for CLI: Recommendations

Recommendations for Endovascular Revascularization for CLI
COR LOE Recommendations

B-R Endovascular procedures are recommended to establish in-line blood flow to the foot in patients with
nonhealing wounds or gangrene.

IIa C-LD A staged approach to endovascular procedures is reasonable in patients with ischemic rest pain.

IIa B-R Evaluation of lesion characteristics can be useful in selecting the endovascular approach for CLI.

IIb B- Use of angiosome-directed endovascular therapy may be reasonable for patients with CLI and nonhealing
NR wounds or gangrene.

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Surgical Revascularization for CLI: Recommendations

Recommendations for Surgical Revascularization for CLI

COR LOE Recommendations

AWhen surgery is performed for CLI, bypass to the popliteal or infrapopliteal arteries (i.e., tibial, pedal) should
be constructed with suitable autogenous vein.

C-Surgical procedures are recommended to establish in-line blood flow to the foot in patients with nonhealing
LD wounds or gangrene.

IIa B- In patients with CLI for whom endovascular revascularization has failed and a suitable autogenous vein is not
NR available, prosthetic material can be effective for bypass to the below-knee popliteal and tibial arteries.

IIa C- A staged approach to surgical procedures is reasonable in patients with ischemic rest pain.
LD

BUERGER’S DISEASE
BMJ Best Practice guidelines
Management approach
Patients often present with critical ischaemia and need admission to hospital at the time of diagnosis.
Critical ischaemia is defined as gangrene or rest pain lasting >2 weeks and requiring regular opioid
analgesia. Its definition may also include ankle pressure <50 mmHg. Patients with non-critical
ischaemia present with either claudication or new onset of rest pain.
Initial admission to the hospital involves confirming diagnosis, excluding differential diagnosis, and arterial
imaging. Vasoactive dilation is done during initial admission to hospital, along with debridement of any
gangrenous tissue. Further treatments are given depending on severity of ischaemia and degree of pain.
Smoking cessation
Smoking cessation reduces the incidence of amputation. It improves patency and limb salvage rates in
those who do undergo surgical revascularisation.Smoking increases flare-ups and reduces ulcer healing. A
return to smoking following cessation may lead to a flare-up of the disease. Risk of Buerger's disease is
thought to be increased by 'bidi' (a home-made cigarette consisting of low-quality tobacco and smoked
without filters) smoking, which is possibly related to cannabis arteritis associated with cannabis use.
Smoking only 1 or 2 cigarettes a day, using smokeless tobacco (chewing tobacco), or using nicotine
replacement therapy may all keep the disease active.
Additional therapies
Several additional therapies have shown some benefit, but the definitive treatment for Buerger's
disease is smoking cessation.
Vasoactive drugs
Nifedipine, a calcium-channel blocker, may cause peripheral vasodilation and improve distal
blood flow. It has been shown to be of benefit in patients with lower limb trophic changes and
symptoms, and is often given in combination with other therapies such as cessation of
smoking, antibiotics, and iloprost.
Pentoxifylline and cilostazol have had good effects, although there are few supportive data. They are
not routinely used. Pentoxifylline has been shown to improve pain and healing in ischaemic ulcers.
Treatment with pentoxifylline can be tried after other medical therapies have failed. Cilostazol could
be tried in conjunction with or following failure of other medical therapies (e.g., nifedipine). It is
contra-indicated in the following: patients with unstable angina, recent myocardial infarction, or
coronary intervention (within 6 months); patients receiving 2 or more other antiplatelet agents or
anticoagulants; and patients with history of severe tachyarrhythmia.
Iloprost is a prostacyclin glandin analogue that may be given intravenously. It has been shown
to be beneficial in relieving rest pain and in healing 62% of ulcers within 4 weeks following a
24-day course. The effects of intravenous prostacyclin analogue iloprost, intravenous
prostacyclin analogue clinprost, and intravenous prostaglandin analogue alprostadil have
been compared and showed no significant difference between them, suggesting they are all
beneficial at healing ulcers and resolving rest pain at 28 days. However, the quality of evidence
in these studies was low to very low. Iloprost, when given orally, shows little significant benefit
in regards to ulcer healing, pain, and amputation rates.

Antibiotics
The choice of antibiotics depends on local hospital policies. Antibiotics are indicated only in the presence
of infection or wet gangrene. Aerobic and anaerobic cover is needed. Amoxicillin/clavulanate may be
adequate, or a penicillin plus metronidazole, or ciprofloxacin (if Pseudomonas is present), or a third-
generation cephalosporin plus metronidazole. If admission to hospital is recommended (when patients
present with critical ischaemia), the antibiotics can be given intravenously.
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Analgesia
Ischaemic pain may require opioid analgesia. Tramadol can be used to treat ischaemic pain.
Alternatively, immediate-release oral morphine can be used in severe cases and substituted with
modified-release morphine when pain is controlled. Severe pain requiring analgesia often requires
admission to hospital so that disease can be controlled or the extent of disease can be assessed.
Non-steroidal anti-inflammatory drugs (NSAIDs) can be used to treat superficial venous
thrombophlebitis. Admission to hospital is not a requirement for giving NSAIDs but may occur
if several medical options are being tried while observing disease severity.
Spinal cord stimulation may also be beneficial. It has been shown to benefit patients with lower limb
symptoms ranging from claudication and pain to ulceration and trophic changes. It is often used after
medical therapy has failed. Spinal cord stimulation is performed by an implantable
stimulator. Intravenous guanethidine
Guanethidine reduces catecholamine release by acting on the Na+-ATPase-dependent pump.
Reduction of rest pain and ulceration healing has been reported with guanethidine injections into the
affected limb, sometimes with the additional use of a Bier block (intravenous regional sympathetic
blockade). Injections can be easily repeated if beneficial effects are seen. Data on its
effectiveness are limited.
Sympathectomy
This can be chemical or surgical, lumbar, or thorascopic. Both positive and negative results have been
reported with lumbar sympathectomy. Sympathectomy may be sufficient to enable necrotic lesions to
heal. It is thought to reduce pain by reducing peripheral resistance and promoting collateral
development. Thorascopic sympathectomy can be used for upper limb symptoms, and lumbar
sympathectomy for lower limb symptoms. Due to the invasiveness of the procedure, sympathectomy is
often a treatment tried when medical therapy has failed and there is no revascularisation option. It is often
used in the more severe cases where there is tissue loss. However, its use has been reported in
patients presenting with claudication.
Intra-arterial thrombolysis
Revascularisation of crural vessels has been reported using intra-arterial thrombolysis,
although it is not a commonly performed treatment modality in Buerger's disease.
Surgical revascularisation
Due to the lack of patent distal vessels, bypass is often not an option. Angiography may reveal
potential distal anastomotic sites, allowing bypass to help ulcer healing. However, primary
graft patency rates are 41% at 1 year, 32% at 5 years, and 30% at 10 years; secondary patency
rates are 54% at 1 year, 47% at 5 years, and 39% at 20 years.
Surgical revascularisation is indicated mainly in patients with critical ischaemia. Patients with non-critical
ischaemia are only indicated for surgical revascularisation if there is severe claudication and a
good vessel to anastomose on to distally.
Intramuscular bone marrow cell administration
Improved ankle-brachial index, transcutaneous oxygen concentration, rest pain, pain-free walking
distance, ulcer healing, and limb salvage have been reported with stem cell therapy. However, no large-
scale, multi-centre, placebo-controlled trials have been conducted to confirm its efficacy or safety.

ENDOVENOUS MANAGEMENT OF VARICOSE VEINS

-Dr. Gulshan Jit Singh

Chronic venous insufficiency is one of the most common medical conditions in the world. The World
Health Organization defines varicose veins of the lower limbs as dilated superficial veins presenting
as baggy or cylindrical in shape and possessing damaged valves . In 70% of cases saphenous veins
are affected. It is reported that 40–60% of women and 25–30% of men will present symptoms of
venous insufficiency during life time . The disease can initially be asymptomatic. After this
asymptomatic period, varicose veins may result in thrombotic complications and venous ulcers.
Most important investigation and tool for management of endovenous approach is:
Duplex ultrasonography:
Duplex ultrasound is capable of imaging the superficial and deep veins of the leg and the communication between
these two systems and is now accepted as the best method of investigating cases of saphenous reflux and
perforating vein incompetence16. It has also been suggested that before deciding upon treatment, all patients with
varicose veins should have a full Duplex examination. This represents a considerable advance over the simple
hand-held Doppler flow detector because it is often very difficult to know exactly from which vessel the reflected
ultrasound is coming. This is not only very valuable in the groin and popliteal fossa, where the deep and
superficial systems meet, but especially helpful in the calf where duplex ultrasound can be used to assess
incompetence of the perforating veins and localize their position.
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Duplex ultrasound has a good specificity but needs further assessment against a reliable ‗gold standard‘.
Ascending phlebography is now no longer used to assess the size and incompetence of calf
communicating veins because, although its specificity is good, its sensitivity is poor. It is unusual for
phlebography to fail to detect any incompetent perforators but duplex ultrasound has now largely replaced
it because it is easier to obtain. Perforator mapping is a time consuming test and is done on the day before
surgery because the sites of incompetent perforators are marked on the skin of the patient with a non
erasable marker. The patient stands in an upright non-weight-bearing position for the affected extremity.
Perforator vein incompetence (PVI) is defined as outward flow of more than 0.3 second (or 0.5 second by
some) or longer than antegrade flow during the relaxation phase after release of manual compression.
Although duplex scanning misses smaller perforator veins, it has 100% specificity and the highest
sensitivity of all diagnostic tests to predict the sites of incompetent perforating veins.
Traditional methods of surgical treatment of varicose veins are being increasingly replaced by less
invasive endovenous ablation methods. The effectiveness of thermal ablation approach has been
confirmed in numerous clinical studies. Recent years have brought new, promising non-thermal
ablation techniques to the forefront.

Endovenous Management has been divided into two categories:

Thermal Ablation Techniques
Endovenous Laser Ablatiom
Radiofrequency Ablation
Steam Vein Sclerosis
Microwave Ablation

Non Thermal Ablation Techniques

Ultrasound Guided Foam Sclerotherapy
Laser Assisted Foam Sclerotrherapy ( LAFOS )
Mechanochemical Ablation ( MOCA )
Clarivein / Flebogrif Catheter
Glue Ablation

Endovenous Laser Ablation

This is associated with high success and low complication rate.
Mechanism of action
The mechanism of vein wall injury after ELA is controversial. It has been postulated to be mediated
both by direct effect and indirectly via laser-induced steam generated by the heating of small amounts
of blood within the vein.(1) This causes thermal damage to the endothelium and sub-endothelial layer
resulting in focal coagulative necrosis and shrinkage leading to thrombotic occlusion in the vein (2)
Histological studies at 3 and 6 months following EVLA indicate failure of endothelial regeneration and
progressive damage to the muscle layers of the vein wall resulting in the further shrinkage. (3)
Diode lasers are most commonly used for ELA. Laser generators exist with multiple different wavelengths,
including lower wavelengths that are considered hemoglobin specific and include 810 nm, 940 nm, 980 nm,
and 1064 nm. Higher wavelengths are considered water specific and include 1320 nm and 1470 nm.
Although it is still not definitively established in the literature, some authors suggest that the higher
wavelength lasers produce similar efficacy at lower power settings with less post procedure symptoms.(4)
It can be performed with multiple different laser fiber designs (ie, bare-tip fibers, jacket-tip fibers,
radial fibers) and diameters available from a variety of vendors. Each of the fiber designs has been
demonstrated to be effective in closing the saphenous vein. At this point, there are no conclusive data
demonstrating a superiority of a given fiber, wavelength and energy deposition combination, efficacy,
significant adverse effects, or complications.
Target Veins
ELA has been successfully and safely used to ablate the great and small saphenous veins .ELA has
been used to treat long straight competent tributary veins outside the superficial fascia, particularly in
patients who are obese and who either sclerotherapy or microphlebectomy would be difficult, time
consuming, or prone to side effects.(5)
Indications
Assessment of patient suitability for EVLA requires ultrasound confirmation of the sites of venous
incompetence, along with history and physical examination. Indications for endovenous treatment are
listed below.
Symptoms affecting quality of life are as follows:
Aching Throbbing
Heaviness Fatigue
Restlessness Night Cramps
Pruritus Spontaneous haemorrhage

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 Skin changes associated with chronic venous hypertension are as follows:
Eczema, and pigmentation
Lipodermatosclerosis
Atrophie blanche
Healed or active
ulceration Edema
Superficial phlebitis (SVT) in varicose veins
Cosmetic (restorative) concerns are indications for
treatment. Anatomical indications are as follows:
Significant reflux documented on DUS examination (reflux >0.5
seconds) Straight vein segment
Intrafascial or epifascial vein segment meeting other anatomical criteria that can be pushed away
from the skin with tumescent anesthetic
Reflux responsible for venous hypertension leading to the clinical abnormalities Ambulatory patient
without contraindication

Contraindications
Patients who are pregnant or breastfeeding (concerns related to anesthetic use and heated blood
effluent that may pass through the placenta to the fetus)
Obstructed deep venous system inadequate to support venous return after ELA
Liver dysfunction or allergy making it impossible to use a local anesthetic (cold saline may be useful
as an alternative)
Allergy to both amide and ester local anaesthetics (cold saline may be an alternative)
Severe uncorrectable coagulopathy (ELA is safe with warfarin use if the international normalized
ratio is between 2 and 3.) (6)
Severe hypercoagulability syndromes (where risk of treatment outweighs potential benefits despite
prophylactic anticoagulants)
Inability to adequately ambulate after the
procedure Sciatic vein reflux
Thrombus or synechiae in the vein or tortuous vein making passage of an endovenous device
impossible (unless multiple access points are chosen)
The use of ELA to close incompetent perforating veins has been described, and studies show a
benefit in ulcer healing and recurrence. (7, 8)

Tumescent anaesthetic: Large volumes of dilute anaesthetic solutions are infiltrated into the
perivenous space of the veins to be treated.
Rationale of its use include as a local anaesthetic,
Its ability to empty the vein to maximize the contact of the thermal device and the vein wall for
efficient thermal transfer to the vein wall.
It provides a protective heat sink around the treated vein to minimize heating of adjacent structures.
Dilute tumescent anaesthetic solution of lidocaine with or without epinephrine in normal saline, often
buffered with sodium bicarbonate (a concentration of 0.1% lidocaine is typically used with an average
volume of about 5–10 mL/cm of treated vein). This should be delivered with ultrasound guidance into the
perivenous space (saphenous sheath) of the vein to be treated. It can be injected either manually or with an
infusion pump, such that upon completion of the process the vein is surrounded along its entire treated
length with the anaesthetic fluid, as demonstrated in the image below.

Transverse ultrasound image of tumescent anesthetic fluid surrounding centrally

located great saphenous vein and laser fiber/sheath.
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 Equipment
Basic equipment and supplies for ELA are listed below.
Procedure table that can tilt to Trendelenburg and reverse
Trendelenburg DUS with at least a 7.5 MHz transducer
Sterile gowns, gloves, masks, drapes, gauze
Ultrasound gel, sterile ultrasound probe and cord
cover Antiseptic preparation fluid
Local anaesthetic
No. 11 scalpel blade, 18-gauge needle 18-
gauge needle for percutaneous entry
21- to 25-gauge needle for administration of tumescent
anesthesia Syringes
Normal saline
Compression stockings.

810 nm (AngioDynamics Queensbury, NY)

940 nm (Dornier MedTech Americas, Inc, Kennesaw,
Ga) 980 nm (Biolitec, Inc, East Longmeadow, Mass)
1064 nm (Sharplan, Inc., NJ)
1320 nm (CoolTouch, Roseville, Calif)
1470 nm (Biolitec, Angiodynamics)

Limited data are available that compare the different configurations, but anecdotally it is thought that
higher, water-specific wavelengths produce less postprocedure pain with equivalent outcomes.
Positioning
Access to the target vein should be performed with the patient in the supine position. The use of a reverse
Trendelenburg position (feet down) in order to increase pressure in the target vein and increase the likelihood of a
successful puncture is advisable, especially with small-diameter veins. Once the sheath and laser fiber are
inserted as described below, the patient is positioned flat and then in the Trendelenburg position after positioning
the laser fiber at the desired starting location. The Trendelenburg position helps to empty the vein and improve
energy transfer from the fiber to the vein wall. This is particularly important at the upper end of the greater
saphenous vein (GSV), where the vein diameter is larger and the vein is less susceptible to spasm

Technique
Perform preprocedural DUS for mapping of the venous segments to be treated. Mark the course of
the vein(s) to be treated and important anatomical landmarks associated with the ablation on the
skin, including the proposed venous access site(s) and deep vein junctions. The access site is
ideally at the inferior end of the incompetent segment or segments of the treated vein. In most
cases, the entire incompetent segment(s) can be treated with 1 puncture. If microphlebectomy will
be performed along with ELA, the veins to be removed should be marked at this time as well.
Prepare the operative tray and equipment. Aside from the thermal ablation device and a venous
access kit, only basic supplies such as gauze, a sterilizing solution, sterile barriers, and the
tumescent solution, with delivery syringes and needle and an ultrasound probe cover, are needed.
Patient is supine with the leg to be treated flexed and externally rotated at the hip, and the knee
slightly flexed.
Carry out sterile preparation and draping of the leg to be treated. Preprocedural antibiotics are not
necessary in almost all circumstances as the procedure is performed sterilely and is considered clean.
Visualize the access site with DUS. Placing the patient in a reverse Trendelenburg prior to the
venous puncture keeps the vein more distended and may facilitate venous access.
Access site should be just above or below knee ( mid calf for SSV).Anesthetize the access site.
Nick the skin just large enough to facilitate entry of the sheath through the skin.
Insert the 18 G needle into the great saphenous vein (GSV) under sonographic guidance.
Place a 0.035-in guidewire into the vein.
Confirm intravenous placement with ultrasonography.
Pass 5 Fr. Sheath over the wire and position to the starting point for ablation i.e., 1 cm. distal to
the junction.
Remove the wire. Check for venous return by aspirating the syringe attached to the sheath and
flush. Recognize that the sheath tip may be against the vein wall and may not aspirate freely.
Also realize that when flushing, microbubbles of air introduced into the vein may produce an
acoustic shadow that may limit the ability to see venous detail and device positions.
Introduce the laser fibre into the sheath so that the fibre reaches the sheath tip. Then fix the
laser fibre and carefully pull back the sheath to expose about 2 cm of fibre. Then withdraw the
entire sheath-laser fibre to the ablation starting spot.

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 Fine tune the location of the tip of the laser fibre to just below the superficial epigastric vein, anterior
accessory GSV (AAGSV), or other large normal junctional vein for the GSV, and just below the thigh
extension junction with the short saphenous vein (SSV) for SSV ablations. Some operators choose to
position the laser fiber 1-3 cm below the saphenofemoral junction (SFJ) without consideration of the
position of the junctional branches. No data support superiority of any of the above procedures in terms
of ablation success, junctional recurrences, or common femoral vein thrombosis post procedure.

Longitudinal (sagittal) duplex ultrasound image of the saphenofemoral junction during the positioning
of the tip of a laser fiber during an endovenous laser ablation. The laser tip is in the greater
saphenous vein (GSV) just beyond the superficial epigastric vein (SEV) origin and is marked by the
arrow. FV=femoral vein.
Connect the laser fibre to its generator and confirm that the tip is in the correct general location by
viewing the visible light aiming beam that can be delivered into the laser fiber tip and visualized through
the skin. This is an additional way to ensure that the tip of the laser is being visualized accurately and that
the laser connections were made appropriately. If the light is not seen in the expected location,
troubleshoot the position of the laser or the connection to the laser to understand why.
Administer tumescent anaesthesia with ultrasound guidance after the patient has been placed
into the Trendelenburg position to help drain the vein.
Place appropriate laser safety goggles on everyone in the procedure room and use other
appropriate laser safety measures. Connect the laser fiber to the laser and verify proper laser
settings. Setting recommendations vary, but aim to deliver at least 70–80 J/cm length of vein
treated: at 14 W this is achieved with a pullback rate of 2 mm/s.
Set the laser to continuous mode and select the power to be used. Re-verify placement of the
laser tip with ultrasound.
Activate the laser and withdraw the fibre and sheath at the speed that is dependent on the amount of
energy you wish to deliver at the power setting selected with the laser in continuous mode. Many
operators deliver 70-100 J/cm at 12 W in continuous mode at 810 nm throughout the length of the
abnormal vein For the GSV and AAGSV, use more energy for the first 10-12 cm (140 J/cm) and less as the
laser tip progresses lower down the leg (100 J/cm to the knee and 70 J/cm below the knee). This is done to
ensure closure of the proximal vein segment just below the deep vein junction, where failure occurs most,
and to decrease the risk of nerve injuries lower in the leg. For the SSV, the use about 110 J/cm for the first
3-4 cm, then 100 J/cm for the next 3-4 cm, and then 70 J/cm for the remaining vein.
Stop laser energy delivery at the distal aspect of the vein and place the laser in standby mode.
Remove the fibre/sheath from the vein. Be sure the entire fibre is removed to exclude the
possibility of a fracture of the device intravascular.
Record the watts, laser on-time, total joules delivered, and length of the segment treated. Calculate the
withdrawal rate and joules delivered per cm to ensure you have reached the targets for success Pearls

Technique considerations
High rates of vein occlusion and ultimate DUS disappearance was noted in a series where the thermal dose
in each segment of the GSV was tailored to the diameter in that segment. The ranges of energies used to
achieve durable ablation included 50 J/cm for veins ≤4.5 mm and 120 J/cm for veins >10 mm in diameter. No
increase in complications was seen with any of the higher energy strategies. (9). In a study comparing
Closure Fast (CF) and ELA, equivalent treatment times and anatomical success at 6 months were seen with
slightly less immediate post procedure bruising and post procedure discomfort noted with CF.(10) Excellent
anatomic success of 90-100% occlusion rates has been shown for lasers with wavelengths between 810 and
1470 nm.(11) Recently, the 1470-nm radial laser fiber has been shown to have the lowest amount of post
procedure bruising, pain, paraesthesia, induration, and superficial phlebitis due to the water-specific
wavelength that is thought to directly act on the vessel wall.(12) Moreover, this study showed equivalent
anatomic success of 99.6% closure at 1 year following use of the 1470-nm radial fiber.

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Complications

Adverse events and complications

Adverse events following ELA occur, but almost all are minor.
Ecchymosis over the treated segment frequently occurs and normally lasts for 7-14 days.
About one week after ELA, the treated vein may develop a feeling of tightness similar to that
after a strained muscle. This transient discomfort, likely related to inflammation in the treated
vein segment, is self-limited and may be ameliorated with the use of nonsteroidal anti-
inflammatory drugs (NSAIDs), ambulation, stretching, and graduated compression stockings.
Superficial phlebitis is another uncommon side effect of ELA, being reported after about 5% of
treatments as mentioned previously. There are no published reports of superficial phlebitis
after ELA progressing to deep vein thrombosis and it has been managed in most series with
NSAIDs, graduated compression stockings, and ambulation.
Neurologic injuries The overall rate of these complications has been shown to be higher in low-
volume centers than high-volume centers. The nerves at highest risk include the saphenous nerve,
adjacent to the GSV below the mid-calf perforating vein, and the sural nerve adjacent to the SSV in
the mid and lower calf. Both of these nerves have only sensory components. The most common
manifestation of a nerve injury is a paresthesia or dysesthesia, most of which is transient. The nerve
injuries can occur with the trauma associated with catheter introduction, during the delivery of
tumescent anesthesia, or by thermal injury related to heating of the perivenous tissues.
In general, paresthesias caused by ELA are usually temporary with the rate of permanent
paresthesias typically reported for GSV and SSV as 0–10%.
Skin burns following ELA have been reported. Skin burns are fortunately relatively rare and
seem to be avoidable with adequate tumescent anesthesia.
DVT following ELA is unusual. DVT can occur as an extension of thrombus from the treated truncal
vein across the junctional connection into the femoral or popliteal veins. The reported rates of
junctional thrombosis following GSV ELA varies widely. This variability may relate to the time of the
follow-up examination and the methods used. Most published series using early DUS (around 72
hours or less after ELA) document a proximal extension for the GSV around 1%.

Endothermal heat-induced thrombosis (EHIT) defines the extent of superficial thrombosis and its extension
into the deep venous system as proposed by Kabnick.(13) EHIT 1 represents thrombus up to the SFJ. EHIT
1 is treated conservatively. EHIT 2 represents thrombus extending into the femoral vein occupying less than
50% of luminal diameter. If identified, EHIT 2 is usually treated with anticoagulation (full or prophylactic
intensity are both used), although some advocate early re-examination and conservative care for more
minor forms. EHIT 3 represents thrombus occupying greater than 50% of femoral vein luminal diameter.
EHIT 4 represents occlusive thrombus in the femoral vein.
EHIT 3 and 4, which are much less common, probably merit full anticoagulation.
Those performing the DUS at a later interval identify a lower rate of EHIT. Possibly, the rates are
different for different operators with different protocols or the proximal extension of thrombus may be
self-limited and may resolve by 1 month without a clinical event. The incidence of junctional extension
of thrombus after SSV ablation has also been described to be low (0-6%).

Neovascularity at the SFJ after ELA, as a form of recurrence of varicose veins, seems to be rare at 1- to 3-
year follow-up. Neovascularization may be less common following endovenous procedures because the
junctional tributary flow, which was usually ligated at their confluence with the SFJ, is generally not affected
with GSV ELA. Case reports of laser fiber fracture or retained venous access sheaths have been made.

Postoperative Care and Instructions

The most common recommendation is for class II compression stockings (30–40 mm Hg) applied
immediately after the procedure and worn for 1–2 weeks. The clinical value of this practice is not
substantiated by data. Anecdotally, patients feel better with the use of compression, especially during
the second week when the pulled-muscle feeling occurs.
Patients are encouraged to ambulate for at least 30–60 minutes after leaving the procedure room and at least 1–2
hours daily for 1–2 weeks. Hot baths, running, jumping, heavy lifting, and straining are discouraged by many
physicians for 1–2 week. NSAIDs may be taken on an as-needed basis for discomfort. Some physicians
recommend a follow-up Duplex 48–72 hours after the procedure to rule out junctional thrombus extension into
deep vein. Extension of thrombus beyond the deep junction extending into the femoral vein for GSV or popliteal
vein for SSV ablation is at most 1%. Moreover, treatment of such non-occlusive extensions is controversial and
increasingly conservative care is recommended. Patients are generally seen at 1 month after the procedure to
assess the results by clinical examination and DUS. Repeat Duplex Ultrasound at about 9-12 months after the
procedure ultimately determines the anatomical success of the ablation.

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Results of Treatment
General comments
ELA is safely and effectively performed using local anesthesia in an office setting requiring about 45–
90 minutes of room time to be performed. Procedure times are dependent on the number of
concurrent treated veins, length of segment(s) treated, and whether ancillary procedures, such as
ambulatory phlebectomy, are carried out. Patient satisfaction has been reported to be very high.
GSV Occlusion
Observational studies report GSV closure rates of 94 – 100 % (assessed by duplex ultrasound) with
relief of symptoms and improvement in the appearance of superficial varicosities. For most studies
the follow up was less than a year (14,15)whilst that for the study reporting 100% success was only 2
weeks (16) In a later report Min et al (17) described the outcome in almost 500 patients followed for up
to 3 years. GSV occlusion rates were 98% at one month and 93% at 2 years (n=121). Delivery of 70-80
J/cm results in optimum GSV/SSV occlusion rates.
Small Saphenous Vein Occlusion
A potential risk to use of EVLA at this site is effect of heat on the common peroneal nerve and its branches
that are in close proximity to the SPJ and proximal SSV. The tumescent anaesthesia should eliminate the
potential for significant nerve injury. The risk of sural nerve injury can be further minimized by canulating
the SSV at or above the mid-point of the calf, the point at which the nerve normally joins the vein. There are
reports of SSV ablation in a total of 78 limbs which describe the success rates of 95% and 97 %( 15, 16).
Although the follow up was relatively short in these studies (Median of 3 months), the results are
encouraging. The total cost (cost of the procedure plus societal cost) of endovenous procedures is likely
equal to or better than that of surgery. This is debatable in a hospital setting, but is almost certainly true if
the ELA can be performed in a non specialized office setting. These techniques are being rapidly adopted
and are now being performed more often than traditional HL/S in the United States.

Anatomical success rates

The anatomical outcomes following endovenous treatment include
Occlusion of the treated segment,
Early failure (complete or segmental).
Late recanalization (complete or segmental).
Anatomic success following ELA should result in the treated vein having no lumen and either shrink
to a fibrous cord < 2.5 mm in diameter or become sonographically absent 6–12 months after treatment.
Anatomical success with ELA of the GSV has been reported between 93–100%. The follow-up for
these evaluations varies from 3 months to 4 years.
Fewer data are published following SSV ablation with ELA but the results are qualitatively similar to that
found with GSV ablations. Patients with a high body mass index have been shown to have a higher rate of
failure with laser.(18) The rationale for this observation is unclear, although it is known that obese patients
have higher central venous pressures and a higher frequency of chronic venous disease. ELA success has
been demonstrated in a retrospective data review to be independent of vein diameter in many studies.
However, a prospective confirmation of this conclusion has not been performed.

Evaluation of Clinical Outcomes

Clinical outcomes from varicose vein ablation can be quantified by numerous reporting systems
Clinical, Etiologic, Anatomic, Pathophysiologic (CEAP)
classification. Revised Venous Clinical Severity Score (VCSS)
Aberdeen Varicose Vein Questionnaire (AVVQ)
Chronic Venous Insufficiency Questionnaire (CIVIQ) 2.
Venous Insufficiency Epidemiological and Economic Study (VEINES).
Varicose Veins (VV) Symptoms Questionnaire (VVsymQ). The VVsymQ may be the best patient-reported
metric because it has been approved by the FDA for use in device and drug trials. Summary
Since its introduction, ELA has replaced ligation and stripping procedures of the GSV and SSV to
eliminate reflux. The procedure has been validated to result in reliable elimination of saphenous vein
reflux, is safe, well tolerated, and durable. In addition, it has been shown to produce less peri
procedural pain, shortening the recovery to allow for earlier return to work.

Radiofrequency Ablation Therapy for Varicose

Veins Technology
The original radiofrequency endovenous ablation system worked by thermal destruction of venous tissues using
electrical energy passing through tissue in the form of high-frequency alternating current. This current was
converted into heat, which causes irreversible localized tissue damage. Radiofrequency energy is delivered
through a special catheter with deployable electrodes at the tip; the electrodes touch the vein walls and deliver
energy directly into the tissues without coagulating blood. The newest system, called ClosureFast, delivers
infrared energy to vein walls by directly heating a catheter tip with radiofrequency energy.

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Energy delivery
In the original radiofrequency catheter system, the catheter was pulled through the vein while feedback is
controlled with a thermocouple to a temperature of 85°C to avoid thermal injury to the surrounding tissues or
carbonization of the vein wall. With the new system, the catheter is held in place while energy heats the catheter to
a specified temperature of 120ºC. As the vein is denatured by heat, it contracts around the catheter. With the
previous-generation radiofrequency system, as shrinkage and compaction of tissue occurred, impedance was
decreased which decreased heat generation; however, this is no longer the case. Only the temperature of the
catheter metal core is monitored as it delivers heat to the vessel wall in 20-second increments. Previously, the
radiofrequency generator could be programmed to rapidly shutdown when impedance rose, thus assuring minimal
heating of blood but efficient heating of the vein wall. In the present system, catheter core temperature is
monitored and adjusts energy to keep the core at 120 º C. Heat delivered to the vein wall causes the vessel to
shrink in the treated area, and the catheter is gradually withdrawn along the course of the vein until the entire
vessel has been treated. This is performed in 7-cm segments.

Catheters
Many different radiofrequency ablation catheters are available for medical applications, but the
Closure catheter, manufactured by VNUS Medical Technologies, is the only commercially available
radiofrequency ablation system designed for venous ablation.

Histologic Findings
Immediately after treatment, biopsy specimens show a significant reduction in the size of the vein
lumen, with denudation of endothelium, thrombus formation, thickened vessel walls, loss of collagen
birefringence, and inflammatory changes. The zone of thermal damage is limited to 2 mm beyond the
point of contact with the electrodes. In more than 90% of patients, biopsy specimens demonstrate
complete occlusion of the vein lumen 6 weeks after treatment. The lumen is completely ablated in
most areas, with some portions of the vessel demonstrating a small residual lumen containing
organized fibrous thrombi. Birefringence is present, and new collagen growth is evident.

Technique
Radiofrequency ablation catheters cannot be easily passed along a tortuous superficial vein;
therefore, the procedure is principally of use in the treatment of truncal varicose veins, such as the
great saphenous vein. Radiofrequency ablation is also used with small saphenous vein incompetence.
Preprocedure
Duplex ultrasonography is used to confirm and map all areas of reflux and to trace the path of the
refluxing great saphenous trunk from the saphenofemoral junction down the leg to the lower thigh or
upper part of the calf. The vein, the saphenofemoral junction, and the anticipated entry point are
marked in same way on the skin. An appropriate entry point is selected just above or just below the
knee, at a point permitting cannulation of the vessel with a 16-gauge needle introducer.

Procedure
The leg is prepared and draped, and a superficial local anesthetic agent is used to anesthetize the site
of cannulation. Needle puncture of the vessel is guided by duplex ultrasonography. The Seldinger
technique is used to place a guidewire into the vessel, and an introducer sheath is passed over the
guidewire, which is removed. The Closure Fast catheter is passed through the sheath, and the tip is
advanced to 2 cm below the saphenofemoral junction under duplex ultrasonographic visualization.
With ultrasonographic guidance, a local anesthetic agent is injected into the tissues surrounding the great
saphenous vein above and within its fascial sheath. The anesthetic is injected along the entire course of the
vein from the catheter insertion point to the saphenofemoral junction. In most patients, 200-400 mL of
lidocaine 0.1% is sufficient to both anesthetize and compress the vessel. Note the importance of delivering
the anesthetic agent in the correct intrafascial location, with a volume sufficient to compress the vein and
dissect it away from other structures, such as nerves, along its entire length.
Duplex ultrasonography is used to position the catheter tip 2 cm below the level of the terminal valve
of the saphenofemoral junction. The catheter must not extend into the femoral vein because injury to
the femoral vein may cause deep vein thrombosis.
In the previous radiofrequency ablation system, when the console is switched on and the test mode is
activated, the baseline impedance should be 250-300 ohms and the baseline temperature should be 32-37°C.
When radiofrequency energy is applied, the thermocouple temperature should rise to 80-85°C within 10-15
seconds. In the new system, when the radiofrequency is activated, the catheter core temperature should
rapidly rise to 120ºC and should be sustained for 15 seconds of the 20-second pulse cycle. If the
temperature does not rise quickly, a malpositioned catheter tip should be strongly suspected.
In the previous system, after the temperature reaches 85°C and remains constant for 15 seconds, the
catheter tip is slowly withdrawn at a rate of approximately 1 cm per minute (1 mm every 6 seconds).

186
 In the new system, two 20-second cycles are performed in the proximal section, after which the
catheter is withdrawn 7 cm as per catheter markings. The next 20-second cycle is repeated once, and,
if 120ºC is maintained, the catheter is then withdrawn another 7 cm until the entire vein is treated.
When proper tumescent anesthesia is applied, the patient should never experience a sudden heat
sensation. If this happens, more anaesthesia is injected.
Post procedure
Post treatment duplex ultrasonography confirms the contraction of the vessel and the absence of flow
along the entire length of the treated vessel. In the previous system, if persistent flow is observed, the
procedure may be repeated immediately, provided the catheter can still be easily passed along the
vessel to the desired site of treatment. In the new system of Closure Fast, the procedure is not
repeated because the targeted vessel typically shows no flow.

Follow-up Care
Compression is of vital importance after any venous procedure. Compression is effective in reducing
postoperative bruising and tenderness, and it can also reduce the risk of venous thromboembolism in both
the treated leg and the untreated leg. A class II (30- to 40-mm Hg gradient) compression stocking is applied
to the treated leg, and, if the patient is willing, it is also applied to the untreated leg. Bed rest and lifting of
heavy objects are forbidden, and normal activity is encouraged. The patient is re-evaluated 3-7 days after
the operation, at which time duplex ultrasonography should demonstrate a closed greater saphenous vein
and no evidence of thrombus in the femoral, popliteal, or deep veins of the calf. At 6 weeks, an examination
should reveal clinical resolution of truncal varices, and an ultrasonographic evaluation should demonstrate
a completely closed vessel and no remaining reflux. If any residual open segments are noted, sclerotherapy
is performed under ultrasonographic guidance.

Complications
Reported complications of the procedure are rare.
Local parasthesias can occur from perivenous nerve injury but are usually temporary.
Thermal injury to the skin was reported in clinical trials when the volume of local anaesthetic
was not sufficient to provide a buffer between the skin and a particularly superficial vessel,
especially below the knee.
Progression of thrombus from local superficial phlebitis has occasionally been observed when
compression was not used. The greatest current area of concern is deep vein thrombosis, with
one 2004 study documenting deep vein thrombus requiring anticoagulation in 16% of 73 limbs
treated with a radiofrequency ablation procedure.(28,29,30)

Outcomes
Published results show a high early success rate with a very low subsequent recurrence rate up to 10 years
after treatment. Early and mid range results are comparable to those obtained with other endovenous
ablation techniques. In one of the series, there has been a 90% success rate, with rare patients requiring a
repeat procedure in 6-12 months. Overall efficacy and lower morbidity have resulted in endovenous ablation
techniques replacing surgical stripping. Patient satisfaction is high and downtime is minimal, with 95% of
patients reporting they would recommend the procedure to a friend. A study by Bush et al indicated that
perforating veins are the most frequent cause of recurrent varicose veins after radiofrequency or laser
ablation. Of 2380 patients involved in the study, 164 had a recurrence of varicose veins, with the median
period to recurrence being 3 years. Among the patients who experienced recurrence, 159 had undergone
great saphenous vein ablation as their initial treatment, including 52 who had concurrently undergone small
saphenous vein or anterior accessory great saphenous vein ablation. Along with perforating veins (64% of
patients), the most common factors behind varicose vein recurrence were as follows. (31)
Recanalized great saphenous vein (29% of patients)
New anterior accessory great saphenous vein reflux (24% of
patients) New small saphenous vein reflux (15% of patients)
It was also found that a higher rate of recanalization occurred with radiofrequency ablation than with
the laser procedure.

187
Features:
Intuitive user interface includes colors, symbols, large fonts and clear instructional
messages Large color screen
Continuous real-time temperature and power feedback
Tones communicate procedure status and prompt user

Steam Vein Sclerosis

This is a technique in which steam is used in pulses through a catheter attached to handle attached to
Generator. This is in use mainly in France. Advantage of this technique is that the steam can be passed
through the dilated tortuous segments of the veins where Laser fibre or RF catheter cannot be negotiated.

Microwave Ablation of Varicose Veins

The microwave probe was inserted into the GSV through a small incision of 5 mm in diameter, just in front of the
malleolus. The procedure is performed under duplex ultrasonography guidance, using a continuous epidural
anaesthesia. With the help of duplex scanning and the flush at the tip of the microwave probe, the catheter tip is
localized 2 cm below the SFJ. The microwave energy is adjusted to 50 W, which has proved to be effective and
safe by previous experiments in vitro and in vivo. The catheter is withdrawn at the average speed of 3 cm/min until
the whole target vessel had been treated. The tumescence anaesthesia was not routinely performed unless in case
of the distance between the vein and skin less than 7 mm by duplex scanning. Immediate duplex scanning was
repeated to reveal whether the GSV had been ablated successfully. The skin incision was closed by a medical
adhesive. The ipsilateral limb was wrapped with elastic bandage for continuous compression.
In 2009, Subwongcharoen et al13 found that EVMWA ( Endovenous Microwave Ablation ) appeared to
be another extremely safe and effective technique for treatment of varicose veins and the best
ablation effect could be obtained while microwave generator with 50-W power setting.
Ultrasound Guided Foam Sclerotherapy
An increasing number of authors have recently reported successful injection of incompetent GSV with 3%
polidocanol in the form of foam.26 The foam is generated by mixing liquid and air in a standardized procedure of
forward and backward movements within a close double-syringe system. The GSV is punctured directly under US
guidance, and the foam injected. Results are verified by serial post treatment duplex examinations.

L.A.FO.S. (Laser Assisted Foam Sclerotherapy)

Dr. A Frullini MD, Florence, Italy presentation at UIP-2015, 27-29 August, 2015, Seoul, Korea
This is a new approach to the incompetent saphenous veins. Holmium laser having 2100-nm wave
length is used and energy delivered between 2.5 – 5 watts. This causes thermal shrinkage due to Type
III collagen fibres of the vein in tunica media without affecting the tunica intima. Intima integrity is
prerequisite for good sclerosis with foam. Vein diameter is reduced so less volume of the foam is
required. As soon as the fibre is retrieved, foam is immediately injected through the same sheath.
Larger vein diameters up to 2 cm. Vein can be treated with this.

Mechanochemical ablation (MOCA)

Tomasz Zubiewicz et al,Acta Angiol Vol. 22 No.4 pp. 137 - 142

Clarivein or Flebogrif Catheter are two different modalities.

All procedures are performed in the operating room. Under ultrasound guidance, the site of GSV puncture is
evaluated and then chosen, usually below the knee joint and at the site of the lowest reflux level to provide
maximum technical success. The puncture is performed using the Seldinger needle provided with the kit, through
which the guiding wire is inserted so that its end is located in the region of saphenofemoral junction. Before
insertion of the 6F introducer sheath, the skin is locally anesthetized with 1% lignocaine at the puncture site.
Using the guiding wire, the FlebogrifTM system is inserted placing its working part 2 cm below the
saphenofemoral junction. The system is freed by sliding the external sheath in relation to the internal mandrile.
The five arms of the working part with sharp hooks on the ends are released and directed toward the wall of the
vessel and scarification of the vein is performed from the positioning site to the puncture site by withdrawing the
system with continuous movement. The speed at which the system is slid amounted to 5 cm/s and the volume of
the injected foam amounted to 1 mL/5 cm of vein. For veins with a diameter of 15 mm 2% polidocanol was used,
and for veins of larger diameter 3% polidocanol. The volume of the sclerosant used for saphenous vein ablation
ranged from 3 to 10 mL with an average of 6.5 mL. After the operation, compression therapy was used with second
grade compression stockings (Sigvaris®) for a minimum of 10 day. Two-years follow-up of the ClariVein system
application proved, that the method was significantly less traumatic compared to thermal methods with its efficacy
reaching 96% . This study presents the results of a 3-month follow-up of application of venous mechano-chemical
ablation system with the FlebogrifTM catheter.

Sapheon Glue Ablation:

Cynoacrylate glue is injected through a catheter with the help of pressure injector into GSV under
ultrasound guidance. Tumescence is not required for this procedure.

188
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 THROMBOPROPHYLAXIS AND DVT MANAGEMENT
-Dr. Rekha Porwal,Dr. Amit Singh

THROMBOPROPHYLAXIS:Venous thromboembolism (VTE), which encompasses pulmonary

embolism (PE) and deep vein thrombosis (DVT), is a major cause of morbidity and mortality in
hospitalized patients. In the majority of these patients, the diagnosis was not suspected before
death, highlighting the fact that fatal PE can be the first manifestation of asymptomatic DVT.
Thromboprophylaxis is, therefore, the most effective strategy to reduce morbidity and mortality
from VTE in surgical patients. Despite this evidence, thromboprophylaxis is underused in
clinical practice because surgeons believe that the risk of VTE is too low to justify the potential
hemorrhagic complications resulting from the use of anticoagulants.

1.1 Risk factors for venous thromboembolism in surgical patients:The risk of VTE is determined by
patient characteristics and the clinical setting. They include, major medical illnesses, obesity, risk
factors such as previous VTE, cancer, age over 60 years, prolonged immobilization, lower limb
paralysis, dehydration, use of hormonal therapy (oral contraceptives or hormone replacement
therapy) and comorbid conditions, such as stroke, congestive heart failure or recent myocardial
infarction. Biochemical abnormalities also may predispose patients to VTE. These risk factors can
be inherited or acquired. Inherited abnormalities include deficiencies of antithrombin, protein C or
protein S, activated protein C resistance, which usually is caused by the Factor V (Leiden) mutation,
and the prothrombin gene mutation. Acquired abnormalities include antiphospholipid antibody
syndrome, myeloproliferative disorders, particularly essential thrombocythemia and polycythemia
rubra vera, and paroxysmal nocturnal hemoglobinuria.

1.2 Risk stratification for venous thromboembolism: patients can be stratified for risk of VTE
according to their age, presence or absence of other risk factors for VTE and the type of surgery that they
are to undergo. Those at low risk do not need specific therapy apart from early mobilization, whereas
those at moderate or higher risk should receive thromboprophylaxis. All hospitalized patients should be
evaluated for both bleeding and VTE risk within 24 hours of admission, upon transferring level of care,
and periodically during the hospital stay. The Caprini Risk Assessment Model should be used to assess
VTE risk in general and abdominal-pelvic surgery patients.[Table 1]
Table 1. Caprini Risk Assessment model
1 point 2 point 3 point 5 point
Age 41-60 Age 61-74 Age ≥ 75 Acute spinal cord
injury (< 1 mo)
Acute MI (<1 mo) Central venous Established Elective lower
access thrombophilia extremity
arthroplasty
BMI > 25 Immobile > 72 hrs HIT Hip, pelvis, or leg
fracture (< 1 mo)
CHF exacerbation Leg plaster cast or History of VTE Stroke (< 1 mo)
(<1mo) brace
History of Malignancy Family history of
inflammatory bowel VTE (1 degree
disease relative)
Procedure with local Surgery-
anaesthesia arthroscopic
Swollen legs or Surgery > 45 mins
Varicose veins
Sepsis (< 1 mo)
Serious lung disease
ex. Pneumonia (<1
mo)
One point for women only
Oral contraceptives or HRT
Pregnancy or postpartum (< 1 month)
History of unexplained stillborn infant,
spontaneous abortion (≥3), premature birth
with toxaemia or growth restricted infant

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1.3 Thromboprophylatic measure s and recommendations: with the use of caprini risk assessment model,
risk assessment score c n be calculated and prophylaxis recommendations are given according to
score. [Table 2] Both mechanical and pharmacologic agents can be used for thromboprophylaxis.
Mechanical methods serve to prevent venous stagnation in the lower limbs by promoting venous
outflow, whereas pharmacolo ic methods act by attenuating coagulation. Compression elastic
stockings and intermittent pneumatic compression are the mechanical methods u sed for prophylaxis,
whereas anticoagulants, such as unfractionated heparin (UFH), low-molecular-weig ht heparin (LMWH)
and warfarin, or antiplatelet agents, particularly acetylsalicylic acid, are the pharma cologic agents
used for this purpose. Low-dose UF H (5000 U subcutaneously 2–3 times daily starting 2 h before the
procedure) and LMWH are bo th effective at reducing the occurrence of DVT in general surgery
patients. A recent addition to this list is synthetic pentasaccharide, known as fonda parinux, which has
been licensed in the United Stat es for thromboprophylaxis.

Table 2. Caprini Risk Assessment Score

Points Risk Recommendations
0 Very Low VTE Risk Early and frequent am bulation
1-2 Low VTE Risk Mechanical Prophylaxi s
3-4 Moderate VTE Risk and Low Pharmacologic Prophylaxis
Bleed Risk
>5 High VTE Risk and Low Bleed Mechanical and
Risk Pharmacologic Prophylaxis
>2 High Bleed Risk Mechanical Prophylaxi s

DEEP VEIN THROMBOSIS (DVT):

2.1. Epidemiology.The true incidence of VTE in India is underreported. In a retrospective st udy in CMC Vellore
from (1996-2005) to determine the incidence of VTE among hospitalized patients showed overall incidence of
confirmed DVT to be 17.6 per 10,000 admissions with 64% being nonsurgical non trauma patients. PE was
diagnosed in 14.9% of the study patients . Mortality in those with confirmed PE was 13.5%.
2.2. Pathogenesis.The earliest case of DVT was described by Sushruta in his book Sushr uta Samhita around
600-900—BC. In 1856 The German ph ysician Rudolf Virchow described three factors that contribute to the
development of VTE, comprising Virchow’s triad: stasis, vessel damage, and a hypercoag ulable state. [Figure
1] Beyond postsurgical and trauma-related cases, stasis may play the largest role in the development of
venous thrombosis. The development of ven ous thrombosis begins at the valves or venou s sinuses. Venous
thrombosis originates as small fibrin deposits in these areas of low flow. The areas of de posits then grow by
apposition to occlude vessels and eventually trigger the coagulation cascades. Similarly, po stsurgical or
trauma related endothelial injury can also trigger this fibrin nidus.

Endothelial damage

Thrombosis
hypercoagulable
blood flow stasis
state

Fig.1: Virchow’s triad

3. Symptoms, signs and physical exa mination

3.1 Clinical presentation of acute lo wer extremity DVT. The clinical presentation of acute lower extremity DVT
varies with the anatomic distribution, extent, and degree of occlusion of the thromb us. Symptoms may range
from absence to massive swellin g and cyanosis with impending venous gangrene. Three patterns of
thrombosis are usually recognized: isol ated calf vein (distal), femoropopliteal, and iliofemoral thrombosis, and
symptoms tend to be more severe as thr ombosis extends more proximally. However, up to 50% of patients
with acute DVT may lack specific signs or s ymptoms. Postoperative patients are, in particular, more likely to
have small, asymptomatic, distal, non-occlusive thrombi. When present, signs and sympto ms of acute lower
extremity DVT may include pain, edem a, erythema, tenderness, fever, prominent superfi cial veins, palpable
cord, pain with passive dorsiflexion of the foot (Homan’s sign), and peripheral cyanosis. Phlegmasia cerulea
dolens, characterized by the triad of m assive swelling, cyanosis, and pain, is the most se vere form of acute
lower extremity DVT and results from complete thrombosis of an extremity’s venous ou tflow. In advanced
cases, it is marked by severe venous hypertension with collateral and microvascular thr ombosis, leading to
venous gangrene. Venous gangrene is particularly associated with warfarin-mediated pro tein C depletion in
patients with cancer or heparin-induced thrombocytopenia. Unfortunately, the diagnosis of DVT based on
clinical signs and symptoms is notoriously inaccurate. The signs and symptoms of DVT are non-specific and
may be associated with other lower extremity disorders, including lymphedema, PTS, superficial venous
thrombosis, cellulitis, musculoskeletal tra uma, and Baker’s cysts. The wells criteria can be used for diagnosis
of a DVT if the clinical suspicion is high. [T able 3]
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 Complications of acute lower extremity DVT
4.1 Pulmonary embolism: The potentially life-threatening consequences of PE make it the most important
short-term complication of acute lower extremity DVT. Symptomatic PE accompanies approximately 10% of
DVT. However, respiratory symptoms correlate poorly with the presence or absence of objectively
documented PE, and as many as 75% of pulmonary emboli may be asymptomatic.
4.2 Post-thrombotic syndrome: PTS, the symptoms of which include pain, edema, skin changes, and
ulceration, is the most important late complication of acute lower extremity DVT. More recent studies
suggest that the PTS develops in 29.6% of those with proximal thrombosis and 30% of those with
isolated calf vein thrombosis.

Diagnosis of lower extremity DVT

5.1 Clinical probability scores (clinical scores):Patients suspected with DVT usually present with
swelling, pain, redness, and warmth in the lower extremity. Currently, the diagnosis of DVT relies on
imaging modalities such as compression and color Doppler US, and computed tomography (CT).
However, only a minority of patients evaluated for suspected DVT with symptoms actually have the
disease and the symptoms of many patients have other causes. In addition, considering the cost and
invasiveness of diagnostic methods, the initial approach for patients with a possible DVT should be
focused on the assessment of their individual pre-test probability (i.e., the likelihood that they have a
DVT), and diagnostic tests should be selected according to the results of pre-test probability.
Clinical probability scores estimate the probability of DVT by incorporating signs, symptoms, and risk factors.
This score stratifies patients into groups according to the probability, which influences the subsequent diagnostic
strategy. Currently, several structured scoring systems have been developed and introduced; the most widely
used and well-studied is the Wells score. The original Wells scoring system published in 1997 consisted of a nine-
component clinical prediction rule for DVT and stratified patients into three categories: ‘high’ (3 or more points)
‘intermediate’ (1-2 points), and ‘low’ (less than 1 point). The prevalence of DVT was estimated as 5.0% (95%
confidence interval [CI], 4%-8%) in the low risk category, 17% (95% CI, 13%-23%) in the intermediate risk category,
and 53% (95% CI, 44%-61%) in the high risk category. In 2003, the original Wells score was modified. A further
component, ‘previously documented DVT’, was added to the original Wells score, and instead of considering
surgery within 4 weeks as a risk factor, the duration was extended to 12 weeks. In place of the three risk
categories in the original version, this version has only two risk categories: ‘likely’ (≥2 points) or unlikely (<2
points).[Table3] The prevalence of DVT according to this ‘two-level’ Wells was estimated as 28% (95% CI, 24%-
32%) in the ‘likely’ group and 6% (95% CI, 4%-8%) in the ‘unlikely’ group.
According to the NICE guidelines, analysis involving 13,086 patients showed that the sensitivity and
specificity for DVT of the Wells score ranged from 77% to 98% and 37% to 58%, respectively. For the
purpose of ruling out DVT, this means that 2 to 23 out of 100 patients with DVT will be missed using the
Wells score; therefore, this test can be considered for ruling out DVT in conjunction with another test. The
specificity suggests that 42 to 63 out of 100 of people without DVT will be identified as having the condition,
suggesting that this score is not suitable for confirming the presence of DVT without further diagnostic
testing. Thus, a clinical probability score, such as the Wells score, cannot be used as the sole diagnostic
modality to confirm or rule out DVT. However, this score enables stratification of subjects into different risk
categories, so that the most appropriate diagnostic or treatment pathway can be followed. The diagnosis of
DVT should be made in conjunction with further diagnostic modalities.
Table 3. Revised Wells score criteria for assessment of suspected DVT

Criterion Score (point)

Active cancer (treatment ongoing or within the last 6 months or palliative) 1
Calf swelling >3 cm compared to asymptomatic calf (measured 10 cm below the tibial tuberosity) 1
Collateral superficial veins (non-varicose) 1
Pitting edema (greater in the symptomatic leg) 1
Swelling of the entire leg 1
Localized tenderness along the distribution of the deep venous system 1
Paralysis, paresis, or recent plaster cast immobilization of the lower extremities 1
ecently bedridden for ≥3 days, or major surgery requiring a regional or general anesthetic in the 1
previous 12 weeks
Previously documented deep vein thrombosis 1
Alternative diagnosis at least as likely as DVT -2
Interpretation: for dichotomized evaluation (likely vs. unlikely)
Score of 2 or higher: deep vein thrombosis is ‘likely’
Score of less than 2: deep vein thrombosis is ‘unlikely’

5.2 D-dimer:After thrombus formation, a fibrinolytic response is immediately activated. The resultant
generation of plasmin causes the release of fibrin degradation products (predominantly D-dimer) into
the circulation. Therefore, the level of D-dimer, a degradation product of cross-linked fibrin, is typically
elevated in patients with acute DVT. A negative D-dimer assay implies that thrombosis is not
occurring and thus has a role in excluding a diagnosis of DVT.

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However, a positive D-dimer assay should be interpreted cautiously because D-dimer levels may also be
increased in a variety of non thrombotic disorders (e.g., liver disease, inflammatory conditions, malignancy,
pregnancy, and following surgery or trauma). However, in conjunction with further diagnostic tests, such as
a clinical probability score or ultrasonography, D-dimer tests can be helpful to rule out DVT.
5.3 Thrombophilia testing:Thrombophilia is an acquired or inherited predisposition to venous
thrombosis. One of the important acquired thrombophilia is the anti-phospholipid antibody syndrome,
which can be detected as a lupus anticoagulant or anti-cardiolipin antibodies. Inherited thrombophilia
includes deficiencies in one of the three natural anticoagulants— antithrombin III, protein C and
protein S, which have been linked with familial venous thrombosis.
In addition, inherited thrombophilia can be caused by factor V Leiden mutation or prothrombin G20210
mutation that can predispose patients to dysfunctional coagulation factors.
According to the international consensus statement published in 2005, screening for thrombophilia
should be performed in:
All patients with a first episode of spontaneous VTE.
Patients with VTE under the age of 50 years even with a transient predisposing factor.
Patients with VTE whose only risk factor is oral contraceptive therapy, oestrogen
replacement therapy, or pregnancy.
Patients with recurrent VTE irrespective of the presence of risk factors.

5.4 Imaging diagnosis of lower extremity DVT

5.4.1 Ultrasound: US is widely used and preferred as a first-line imaging modality for the diagnosis of
proximal DVT. It is non-invasive, can easily be performed at the patient’s bedside, and sufficiently
reliable for serial evaluation. The inability to fully collapse a venous segment under gentle US probe
pressure is considered diagnostic of DVT. US evaluation for DVT is often combined with real-time
Doppler imaging, such as duplex, continuous-wave, and colour-flow Doppler imaging. Duplex US
imaging can assist in the characterization of a clot as obstructive or partially obstructive.
US examination has high sensitivity and specificity for the diagnosis of symptomatic proximal lower
extremity DVT when compared to conventional venography. However, the diagnostic performance of US is
consistent in the femoral and popliteal vein, but less consistent in the iliocaval region and below the knee.
5.4.2 Venography: Conventional contrast venography is the gold standard for the diagnosis of lower extremity
DVT. In this technique, proximal compression tourniquets are applied, and a series of overlapping radiographs are
obtained after injection of contrast medium into a dorsal vein in the foot to outline the entire deep venous system
of the lower extremity. DVT is diagnosed by the presence of a constant intra-luminal filling defect that is present in
more than one view; non-filling of a venous segment despite repeated injection is suspicious, but not diagnostic,
of DVT. However, venography is not uniformly available, uncomfortable for patients, and contraindicated in
patients with renal insufficiency and severe allergic reactions to contrast medium. Further, inadequate imaging is
common in venography; visualization of a venous segment is inadequate in 20% of cases. The dorsal foot vein
cannot be cannulated in 5%. Also it can be difficult to interpret, and the designation of ‘DVT present’ or ‘DVT
absent’ is subject to a considerable degree of intra- and inter-observer variation. Thus, venography is now rarely
used in clinical practice and many hospitals are unable to perform the procedure. However, venography is still the
reference standard test for DVT, and can be used when other tests are unable to definitely exclude the diagnosis
of DVT or for planning endovascular treatment.
5.4.3 CT venography: CT venography has recently been documented as a rapid and available
alternative to ultrasonography for lower extremity DVT, with sensitivity and specificity of 89%-100%
and 94%-100%, respectively. CT venography typically involves injection of contrast media into an arm
vein, followed by multi-detector CT imaging timed to coincide with opacification of the deep veins of
the legs to allow assessment of these veins for thrombus. Intravenous contrast media, ranging from
100-150 mL, is used with an injection rate of 3-4 mL/s. CT venography can also be incorporated into a
comprehensive examination that includes pulmonary CT angiography for evaluation for both PE and
proximal DVT. CT venography is a non-invasive technique and has an inherent advantage of cross-
sectional imaging to identify the extra vascular sources of extrinsic compression, presumably an
underlying cause of DVT. However, it shares the disadvantage with conventional contrast venography
of requiring exposure to ionizing radiation and use of iodinated contrast media.
5.4.4 Magnetic resonance venography: Magnetic resonance (MR) venography is a noninvasive imaging modality
that shares many of the clinical advantages of US, such as preventing exposure to ionizing radiation or iodinated
contrast media. MR venography has the advantage of cross-sectional imaging for delineation of extra vascular
anatomy and identification of potential sources of extrinsic venous compression that may be an underlying cause
of lower extremity DVT or suggest alternative conditions that mimic DVT. Therefore, MR venography may be the
test of choice for patients in whom ultrasound is not feasible.

Management of DVT: Theprimary goals for treatment of a DVT include:

Prevent further clot extension.
Prevent pulmonary embolism.
Reduce the risk of the patient developing a chronic venous insufficiency.
Reduce the risk of recurrence of DVT.
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6.1 Anticoagulation therapy: Preliminary assessment- Before embarking upon anticoagulant therapy,
consideration should be given to 1) investigating disorders underlying the development of DVT or PE, 2)
ensuring it is safe to anticoagulate the patient, 3) ensuring that monitoring of anticoagulation can be carried
out safely and accurately, and 4) clinical assessment of the risks of anticoagulation. Good clinical history
taking, physical examination and some laboratory tests are essential in the assessment of factors
contributing to the development of DVT and the fitness of the patient for anticoagulation. Due to their
pharmacology, the anticoagulants most often used in the management of DVT require assessment of
baseline coagulation and renal function prior to embarking on therapy. Use of a vitamin K antagonist (VKA)
or low-molecular-weight heparin (LMWH) in patients with impaired renal function could increase the
bleeding risk. A baseline assessment of the prothrombin time (PT) and the activated partial thromboplastin
time (aPTT) is required to identify prolongation of clotting times, which might contraindicate anticoagulation
or complicate monitoring. All patients embarking on anticoagulation with heparin or LMWH should have a
baseline platelet count performed before starting.
6.1.2 Choice of anticoagulation therapy:All patients diagnosed with DVT or PE should undergo
anticoagulation. Because anticoagulation therapy requires long-term treatment (>3 months), VKA oral
anticoagulant is the standard treatment. Unless the patient is pregnant, which is a contraindication for VKA,
there are few reasons to choose other anticoagulants. Adjusted-dose subcutaneous unfractionated heparin
(UFH) is an effective alternative to VKA, but LMWH is more popular because UFH requires initial laboratory
monitoring and twice-daily injection, and is associated with osteoporosis.
Treatment with LMW heparin, fondaparinux, or unfractionated heparin should be continued for at least 3
days and oral anticoagulation with a vitamin K antagonist should be overlapped with LMWH fondaparinux or
UFH for at least 3 days. Warfarin should be initiated simultaneously with the heparin, at an initial oral dose
of approximately 5 mg/day. The heparin product can be discontinued on day 3 if the INR is therapeutic. Oral
anticoagulation with a vitamin K antagonist should prolong the INR to a target range between 2.0 to 3.0.
For patients receiving UFH, ACCP guidelines suggest that platelet counts be obtained regularly to monitor
for the development of thrombocytopenia. The heparin product should be stopped if any one of the
following occurs: a precipitous or sustained fail in the platelet count, or a platelet count <100,000/microL.
In special situations anticoagulant of choice:
Malignancy- LMWH is the preferred anticoagulant for long-term use.
Pregnancy- LMWH is the preferred anticoagulant for pregnant women with acute DVT.
Renal failure- IV UFH is the preferred anticoagulant in those with severe renal failure.
Hemodynamic instability- IV UFH is the preferred anticoagulant in those with hemodynamic
unstable.
Extensive clot Burden- IV UFH is the preferred anticoagulant in those with extensive DVT or
phlagmasia cerula dolens.
Obesity- there is no preferred agent in patients who are obese. However therapeutic
anticoagulation can be assured with IV UFH.
Heparin induced thrombocytopenia- for patients with DVT and a diagnosis of heparin induced
thrombocytopenia, anticoagulant with heparin, including UFH and LMWH is contraindicated.
Anticoagulation with a non heparin anticoagulant (Dabigatran, fondaparinux) should be administered.
Recently, new oral anticoagulants (NOACs), such as rivaroxaban, dabigatran, apixaban, and edoxaban, have
been evaluated for treatment of DVT and are now available in many countries. These are attractive preferred
alternatives to warfarin for long-term management of patients with VTE. However, whether the NOACs have
a more favourable risk-benefit profile than warfarin during long-term treatment is unclear.
6.1.3 Duration of therapy: most patients with a first episode of DVT should receive anticoagulation for
a minimum of 3 months. Extending anticoagulation beyond 3 months is not routinely considered in
patients who have a provoked DVT with the following: transient risk factors, assuming the risk factor
is no longer present(e.g. surgery, cessation of hormonal therapy), isolated distal DVT, sub segmental
or incidental pulmonary embolism(PE), or those in whom the risk of bleeding is considered to be high.
Patients who should be considered as candidates for indefinite anticoagulation are recurrent DVT and
diagnosed thrombophilia.
6.2 Compression therapy: Post thrombotic syndrome (PTS) is a burdensome complication that develops in
25%-50% of patients after acute DVT. Its clinical features range from minor limb swelling and discomfort to
severe leg pain, edema, skin changes and even ulceration. Because no effective treatment options are
available, prevention of PTS is crucial. Compression stockings can prevent PTS by reducing venous
hypertension and reflux, and can be used to both mitigate leg complaints and reduce the risk of PTS after
acute DVT. Because there is no evidence of the benefit of continuing compression stockings use in patients
beyond 2 years, this is a decision for the individual patient and their physician. During the acute stage of
DVT, 20-30 mmHg graduated compression stockings are recommended. Below-knee compression stockings
are preferred over thigh length for prevention of PTS in patients with proximal lower extremity DVT.
6.3 Endovascular treatment of acute lower extremity DVT: DVT thrombolysis has the potential to reduce the risk of
PE and the incidence of PTS. Endovascular therapy for DVT consists of catheter-directed thrombolytic therapy
(CDT) inserts a catheter into the blood clot through which the thrombolytic agent (Urokinase or r-tpa) is infused
and percutaneous mechanical thrombectomy (PMT). PMT is usually combined with thrombolysis and additionally
involves mechanical agitation or disruption of the large thrombus.
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Similarly, the thrombus can be removed using suction catheters in combination with thrombolytic
agents. Carefully selected patients with low bleeding risk (often younger patients) with extensive
proximal iliofemoral DVT may benefit from thrombolysis, particularly CDT, in which bleeding rates are
lower than the systemic thrombolytic therapy.
Beneficiaries for endovascular treatment includes-
Endovascular treatment is not routinely recommended in patients with lower extremity DVT.
Endovascular treatment can be considered in patients with acute symptomatic iliofemoral
DVT with a low risk of bleeding.
Endovascular treatment for femoropopliteal DVT can be considered in patients with
progression of DVT despite anticoagulant therapy or those with severe symptoms.
Endovascular treatment should be considered in patients manifesting venous gangrene or
phlegmasia cerulea dolens with a low risk of bleeding.

6.4 inferior vena cava filters: inferior vena cava filter placement is recommended when-
Contraindication to anticoagulation.
Recurrent PE despite therapeutic levels of anticoagulation.
Very poor cardiopulmonary reserve
For patients with a temporary contraindication to anticoagulation, placement of a nonpermanent,
retrievable filter is appropriate. Retrievable filters can be left in place for weeks to months or can
remain permanently, if necessary.

6.5 Surgical treatment of acute lower extremity DVT: Anticoagulation therapy is the main treatment option
for acute femoropopliteal DVT, but anticoagulation only in extensive iliofemoral DVT is not sufficient to
prevent later development of chronic venous insufficiency and postphlebitic syndrome. Therefore, early
thrombus removal is necessary. However, surgical venous thrombectomy is an invasive treatment with
possible complications of anaesthesia, bleeding, or PE. Surgical venous thrombectomy is recommended in
selected patients who are candidates for anticoagulation but in whom thrombolytic therapy is
contraindicated. Especially in patients with limb-threatening venous ischemia, such as venous gangrene or
phlegmasia cerulea dolens, aggressive thrombus removal should be considered if the patient's general
condition is acceptable. Surgical venous thrombectomy can be performed in selected patients: a first
episode of acute iliofemoral DVT, symptoms <14 days in duration, a low risk of bleeding, ambulatory with
good functional capacity and an acceptable life expectancy.

6.6 Surgical treatment of chronic lower extremity DVT: Patients with chronic DVT who are not
candidates for endovascular repair or those who failed attempts of endovascular revascularization
can undergo open surgical reconstruction. Common open procedures for chronic DVT includes-
1.Palma-Dale procedure- a useful technique for venous reconstruction in patients with
proximal outflow obstruction. This operation, which was designed for patients with chronic
unilateral iliac vein obstruction of any aetiology, requires a normal contralateral iliofemoral
venous system to ensure venous drainage.
In the crossover bypass, the great saphenous vein of the non-affected limb is exposed and
rotated at the saphenofemoral junction. An alternative to use of the autologous saphenous
vein is use of a 10 mm PTFE graft for femoro-femoral bypass procedures when an adequate-
caliber saphenous vein is not available.
2.In-line bypass- performed for femoroiliocaval obstruction associated with segmental
obstruction. An expanded PTFE graft is most commonly used. An arteriovenous fistula is
created distally to maintain adequate inf low.
3.Endophlebectomy- is an open surgical technique in which the post thrombotic vein is
longitudinally exposed at various segments and the synechiae attached to the intimal layer are
carefully removed using scissors at the base.

References:
Seung-Kee Min, Young Hwan Kim, Jin Hyun Joh, et.al Diagnosis and Treatment of Lower Extremity Deep Vein
Thrombosis: Korean Practice Guidelines. Vascular Specialist International. Vol. 32, No. 3, September 2016;32(3):77-
104. http://dx.doi.org/10.5758/vsi.2016.32.3.77.
Sasan Behravesh, Peter Hoang, Alisha Nanda, et.al Pathogenesis of Thromboembolism andEndovascular
Management. Thrombosis Volume 2017, Article ID 3039713. http://dx.doi.org/10.1155/2017/3039713.
Jennifer Lai, et al Venous Thromboembolism Prophylaxis– Adult– Inpatient/Ambulatory– Clinical Practice Guideline.
University of Wisconsin Hospitals and Clinics. October 2014.
Vimalin samual, Edwin Stephen. Overview of Management of acute deep vein thrombosis. Chapter 192; page 876-878.
Medicine update 2017 volume 3.
Harinder singh bedi. Pulmonary embolism. Chapter 193; page 879-885. Medicine update 2017 volume 3.

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 MANAGEMENT OF RENAL CELL CARCINOMA
-Dr. Pawan Lal, Dr. Pranav Mohan Singhal

Renal cell carcinoma (RCC) accou nts for 2-3% new cancers diagnosed these days . Patients typically
present between 50-70 years of age, with the mean age at diagnosis being 64 years.
90% of renal tumors are renal c ell carcinomas, and 80 % of renal cell carcinom as are clear cell
tumors.The incidence of RCC is increasing worldwide.

Although RCC happens to be pred ominantly a tumor of the adults, the incidence of RCC in childhood
happens to be 2.3- 6.6 %.During the first decade of life, incidence of wilms tumor is mo re than RCC,
which happens to reverse in second decade with RCC being more common than wilms.

RISK FACTORS FOR RCC- Multipl e risk factors are associated with RCC, common one s being
Tobacco exposure with a relative risk of 1.4-2.5 happens to be an important fac tor with duration
of exposure playing an important r ole.
Hypertension
Low socio- economic background
Exposure to metallic chemicals and rubber industries.
Retroperitoneal radiation expo sure , specially while treating wilms tumor
Hereditary factors, most important being Von Hippel-Lindau.

PATHOLOGY OF RCC
MORPHOLOGY--Most RCCs are round to ovoid and circumscribed by a pseudo-capsule of compressed
parenchyma and fibrous tissue and are not grossly infiltrative, except collecting du ct carcinoma and
sarcomatoid variants.
GRADING-- has been based primarily on nuclear size and shape and the presence or absence of
prominent nucleoli. Fuhrman's system is used for R CC generally and for clear cell RCC in particular.

Frank invasion and perforation of the ren al capsule, renal sinus, or collecting system are fou nd in
approximately 20% of cases with displacement of these structures being a more common finding.
Most sporadic RCCs are unilateral and unifocal. Bilateral involvement can be synchronous or
asynchronous and is found in 2% to 4% of sporadic RCCs, (familial forms of RCC, such as von Hippel-
Lindau disease).All RCCs are adenocarcinomas.

CLINICAL PRESENTATION
60% of RCC are now detected incidentally.
Symptoms associated with RCC ca n be due to local tumor growth, haemorrhag e, paraneoplastic
syndromes, or metastatic disease.
The classic triad of Flank pain, Gr oss Haematuria, and Palpable Abdominal Ma ss is now rarely
found.Important presentation of RCC is Spontaneous Peri-renal Haemorrhage with underlying
Paraneoplastic syndromes in 10-20% of patients with RCC.
Symptoms of localized disease- Haem aturia, flank pain, abdominal pain
Symptoms due to Obstruction of the inferior venal cava- B/l lower extremity edema,
Symptoms of Systemic Disease-Pe rsistent cough, bone pain, cervical lymphadenopathy, constitutional
symptoms, Weight loss/fever/malaise, P araneoplastic syndromes.

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HYPERCALCEMIA
The production of parathyroid hormo ne–like peptides is the most common cause of hypercalcemia.
Patient presents with Nausea, anorexia, fatigue, and decreased deep tendon reflexes. Medical
management -vigorous hydra tion followed by diuresis with furosemide and th e selective use of
bisphosphonates, corticosteroids, or Calcitonin.Bisphosphonates is the treatment of choice

STAUFFERS SYNDROME-
Non-metastatic hepatic dysfunction, which has been reported in 3% to 20% of cas es. Serum alkaline phosphatase
levels are elevated, 67% h ave elevated prothrombin time or hypoalbuminemia, and 20% to 30% have elevated serum
bilirubin or transa minase levels.Discrete regions of hepatic necrosis, with elevated serum
IL-6 levels. Hepatic function normalize s after nephrectomy. Biopsy- nonspecific hepatiti s with lymphocytic
infiltrate.It is necessary to ex clude metastasis as a cause of hep atic dysfunction.

SCREENING
Target Populations
Patients with End-Stage Renal Disease -Screen only patients with long life expectancy and minimal major
comorbidities
-Patients with Autosomal Dominant Polycystic Kidney Disease-Routine screening is n ot justified.
METHOD-Periodic ultrasound examination or CT scan beginning during third year on dialysi s.

PROGNOSIS-
Pathological stage is the single most im portant prognostic factor for RCC. Organ confined disease
having a 5 year survival rate of 70-90% with perine phric fat invasion -15-20% reduction in 5 year surviv
al. Renal sinus and collecting system invasion confer poorer prognosis.
Direct invasion of wall of vein is more important than the caudal extent of the tumor th rombus
Lymph node involvement – bad progn osticating sign with 5 year survival of 5-30%.
Metastasis – shows poor prognosis

INITIAL workup of patient with renal m ass

Frequency of incidental detection of RCC has increased due to availability of better imagin g modalities.
Fewer patients presents with the classical triad.Patients may present with signs and symptoms related to
metastasis, like bone pain, adenopathy and respiratory symptoms. Other symptoms include fever, we
ight loss, anaemia, varicocoele.Thorough physical examination and history, laboratory investigations
includin g CBC, S. calcium, KFT, LFT,

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Urinalysis
CT of the abdomen with or without pelvic CT and chest radiograph are essential studies in the initial workup, and
for metastatic workup, at the very least chest x-ray should be done.Abdominal MRI is used to evaluate the inferior
vena cava if tumor involvement is suspected.MRI can also be used for staging when contrast material cannot be
administered because of allergy or moderate renal insufficiency. A central renal mass may suggest the presence
of urothelial carcinoma; if so, urine cytology, uteroscopy, and biopsy should be considered.
Most bone and brain metastases are symptomatic at diagnosis. Therefore, a bone scan is not routinely
performed unless the patient has an elevated serum alkaline phosphatase (ALP) or complains of bone.

WORKUP OF LOCALIZED RCC

20% of solid enhancing T1 renal masses are benign, mostly oncocytomas or atypical AML. Young to middle
aged females (40%) usually have benign pathology, contrary to men.There is a direct relationship between
tumour size and malignant pathology and aggressiveness (tumor grade, invasive phenotype, histology).
Benign were 30 %(< 2cm), 21 %( 2-4cm), 9.5 %( T1b) with some studies suggesting a cut-off point of
3cm, between benign and malignant tumors.

Biopsy can help predict Tumor behaviour based on histology, but should only be used in
people being offered wide management options.

Alternative to biopsy is PET scanning combined with radioactively labelled anti-CA-IX

monoclonal antibodies.—specificity for clear cell and type 2 papillary.

TREATMENT OF RCC
Surgical resection remains an effective therapy for clinically localized RCC, with options including
Radical Nephrectomy (RN) and nephron-sparing surgery.
RN has fallen out of favour for small tumors due to its predisposition to Chronic Kidney Disease.
Multiple retrospective series have concluded in favour of Partial Nephrectomy for T1 tumors.
However the EORTC trial in 2011 has raised controversy- showed lower perioperative mortality with
RN and better renal function with PN. Better cardiovascular status and 10 year survival rate with RN.
Medical and surgical CKD are different. Survival of CKD-Surgical patients was similar to those
of patients with NO CKD.

PARTIAL VS RADICAL NEPHRECTOMY

Partial Nephrectomy is preferred for small renal masses (T1a, <4.0 cm), it is also strongly preferred
whenever preservation of renal function is potentially important, such as patients with pre-existing CKD.

RADICAL NEPHRECTOMY
A radical nephrectomy includes an early ligation of renal artery and vein, peri-fascial resection of the
kidney, peri-renal fat, regional lymph nodes( crus of diaphragm to aortic bifurcation), and ipsilateral
adrenal gland.Extended lymphadenectomy doesn’t show any distinct advantage, only 2-3% those with
micro-metastases benefit from extended lymphadenectomy.
As it is RCC metastasizes through the bloodstream independent of lymphatic drainage.
Approach can be extended subcostal, midline, extra-peritoneal flank incision in elderly.
In Low to moderate volume, localized RCC, with no local invasion and minimal venous involvement
and manageable Lymphadenopathy Laparoscopic RN can be considered.

Entails complete local resection of tumor while leaving behind largest amount of normal
functioning parenchyma.
Indications for PN- Where Radical Nephrectomy would render patient Anephric or in need of
Dialysis. Margin width is immaterial as long as margins are tumor free.Functioning remnant of 20-
30% of one kidney is important to avoid ESRD.If PN not feasible, then downsize tumor using
tyrosine kinase inhibitors and then do PN.Local recurrence after PN for T1a is 1-2% and is due to
undetected multifocal RCC in renal remnant and overall survival was > 90%.Post surgery renal
function depends on – number of preserved nephrons is the primary factor, ischemic injury plays
the secondary role.As long as warm ischemia time is < 25 minutes and or hypothermia is applied
most preserved nephrons will recover their function.Patients with more than 50% reduction in
overall renal mass were found to be at an increased risk for proteinuria, FSGS, and renal failure.
Protienuriais the initial manifestation – obtain 24 hour urinary protein measurement yearly to
assess for Hyperfilteration Nephropathy. Use ACE inhibitors and Low protein diets.

THERMAL ABLATIVE TECHNIQUES: Include Renal Cryosurgery and RFA, and is an alternative to PN.
Can be done laparoscopically/ percutaneous routes, but are associated with higher local recurrences.
Ideal candidates – advanced age, comorbidities, local recurrences after previous PN, patients with
Hereditary RCC with multifocal lesions requiring multiple PN. Success rate is highest for Tumors 2.5-
3 cm, and not for tumors>4cm. Cryosurgery temperature of 20c, shows iceball phenomenon.
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Cryosurgery complications include – Renal fracture, Haemorrhage, adjacent organ injury, ileus,
wound infection.RFA is done at a temperature of 41c of tissue temperature.RFA complications are
ARF, uretero-pelvic junction stricture, necrotizing pancreatitis, lumbar radiculopathy.
ACTIVE SURVEILLANCE - CRITERIA
Small, solid, enhancing, well marginated, homogenous renal lesions in elderly or patients with poor surgical
risk can be safely managed with observations and serial imaging at 6months or 1 year intervals.
Not advisable for patients with tumor>3 cm, poorly marginated, non-homogenous, with biopsy
advocating aggressive tumor. Not advisable in younger patients as well.
FOLLOW-UP MEASURE RECOMMENDATION

Percutaneous biopsy Percutaneous biopsy may be considered prior to active surveillance.

Abdominal imaging Cross-sectional scanning (CT or MRI) within 6 months of active surveillance
initiation to establish a growth rate, with continued imaging (US, CT, or MRI)
at least annually thereafter.

Chest imaging Patients with biopsy-proven renal cell carcinoma or a tumor with oncocytic
features on active surveillance should undergo annual CXR.

VENOUS INVOLVEMENT
Venous involvement in RCC is 4-10%45-70 % patients with RCC and IVC involvement can be cured
with aggressive surgical approach.IVC Thrombus is suspected in patients with Lower extremity
edema, isolated right sided varicocoele, dilated superficial abdominal veins, proteinuria, pulmonary
embolism, right atrial mass etc.
Staging of IVC thrombus levels
1- adjacent to renal vein ostium
2-extending to lower aspect of liver
3-involving intrahepatic IVC
4-Extending above diaphragm
Even stage 4 IVC thrombus can be cured with surgical resection without any metastases.
MRI is the imaging modality of choiceSurgical approach is tailored to the level of the IVC thrombus.

MANAGEMENT OF PRIMARY NON-MUSCLE INVASIVE

UROTHELIAL BLADDER CANCER
- Dr. Gagan Gautam Vineet Goel, Ashwin Tamhankar,Puneet Ahluwalia,

EPIDEMIOLOGY
Globally, bladder cancer accounts for approximately 390,000 cases and 150,000 deaths each year. In
developed areas of the world, such as North America and Western Europe, these bladder cancers are
predominantly urothelial (formerly called transitional cell). Approximately 70 percent of new urothelial
bladder cancer cases are classified as non-muscle invasive. Non-muscle invasive bladder cancer
(NMIBC) includes Ta (papillary), T1 (submucosal invasive) tumors and Tis (carcinoma in situ [CIS],
which account for approximately 70, 20, and 10 percent of non-muscle invasive cancers, respectively.

Subtypes of NMIBC
There are 3 subtypes:
Ta
Confined to urothelium above BM
Papillary configuration
‘Seawood ‘protruding in lumen of bladder
T1
Penetrated basement membrane and infiltrated lamina propria but not detrusor muscle.
Most are papillary.
Few are nodular(deepest into lamina)
Tis
Although confined to urothelium, it is high grade Carcinoma (Anaplastic)
Flat, disordered, non papillary configuration.
Cystoscopic appearance- slightly elevated velvety patch of mucosa.
CIS is often multifocal and diffuse and can occur in the bladder, but also in the upper urinary
tract, prostatic ducts, and prostatic urethra.
Missed at cystoscopy, as inflammatory lesion if not biopsied.
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 Overview of a suspected case of Carcinoma Urinary Bladder

PRIMARY ASSESMENT IN NMIBC

Urine Cytology
The examination of voided urine or blad der-washing specimens for exfoliated cancer cells h as high sensitivity in G3
and high-grade tumors (84%), but lo w sensitivity in G1 and low-grade tumors (16%). T he sensitivity in CIS detection
is 28-100%. Cytology is useful, particularly as an adjunct to cystoscopy, if G3/CIS malignancy is present. Positive
voided urinary cytology can indicate an urothelial tumour anywhere i n the urinary tract; negative cytology, however,
does not exclude the presence of a tumour. Cytological interpretation is user-dependent. Evaluation can be hampere
d by low cellular yield, urinary tract infections, stones, or intravesical instillations, but in experienced hands s
pecificity exceeds 90 %. One cytospin slide from the sample is usually sufficient. In patients with suspect cytolo gy it
is reasonable to repeat the investigation.
Urinary Molecular Marker Tests
Recently, a large number of urinary mo lecular tests have been identified. None of these markers have
been accepted for diagnosis or follow-up in r outine practice or clinical guidelines. Some urine te sts that
have been evaluated in several laboratories/centres and with sufficient numbers of patients are listed in
table below. The following conclusions can be drawn regarding the existing tests:
Sensitivity is usually higher at the cost of lower specificity, compared to urine cytology
Benign conditions and BCG influence many urinary marker tests.
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 Requirements for sensitivity and specificity of a urinary marker test depend on the clinical context of
the patient (screening, primary detection, follow up [high risk, low-/intermediate-risk]).
Unlike other urine tests, false-positive results of UroVysion and microsatellite analysis can be
attributed to occult disease and these markers therefore identify patients likely to experience early
recurrence and possibly progression.

Applications of Urinary Molecular Markers:

Screening of the population at risk of bladder cancer
Exploration of patients after haematuria or other symptoms suggestive of bladder cancer
(primary detection): It is generally accepted that none of the tests can replace cystoscopy.
However, urinary cytology or markers can be used as an adjunct to cystoscopy to detect
invisible tumors, particularly CIS.
Surveillance of NMIBC
Cystoscopy
The diagnosis of papillary cancer ultimately depends on cystoscopic examination of the bladder and
histological evaluation of the resected tissue. CIS is diagnosed by a combination of cystoscopy, urine
cytology, and histological evaluation of multiple bladder biopsies. Cystoscopy is initially performed in
the office with flexible cystoscopy giving better compliance especially in men.

Diagnostic Transurethral Resection of Bladder Tumor (TURBT).

The initial treatment of presumed non-muscle invasive bladder tumors is a complete transurethral
resection of all visible bladder tumors (TURBT) with adequate depth and should include muscularis
propria. The quality of the TURBT is of primary importance. An examination under anesthesia (EUA)
should also be performed since the presence of induration or a palpable mass suggests muscle
invasive disease. A single post-operative instillation of intravesical chemotherapy is recommended in
appropriately selected patients. Resection should also include biopsy of focal areas of suspected
carcinoma in situ (CIS), and abnormal areas in the prostatic urethra and bladder neck. Most patients
can be successfully managed conservatively; however, a minority will require more aggressive
surgery. If the initial TURBT reveals muscle invasive disease, more aggressive treatment is indicated.

Purpose of TURBT
Confirmation of diagnosis
complete eradication of all visible tumor
tissue resection for pathologic evaluation
(grade/stage) New Method of Tumor Visualization
As a standard procedure, cystoscopy and TURB are performed using white light. However, the use of white
light can lead to missing lesions that are present but not visible.Endoscopically, urologists can suspect
malignancy only on the basis of the presence of visible changes such as tumors or “red spots.”

Photodynamic diagnosis (fluorescence cystoscopy)

Photodynamic diagnosis (PDD) is performed using violet light after intravesical instillation
of 5-aminolaevulinicacid (ALA) or hexaminolaevulinic acid (HAL).
Photoactive porphyrins accumulate preferentially in neoplastic tissue. Under blue light they
emit red fluorescence,
Higher sensitivity (92% vs. 71%) for CIS and papillary tumors (96%vs. 85%)
Lower specificity (63%vs. 81%)
Decreases recurrence rates in patients who undergo HAL fluorescence cystoscopy
compared with controls.
Narrow Band Imaging
In narrow-band imaging (NBI), the contrast between normal urothelium and hyper-vascular cancer
tissue is enhanced, aiding in accurate biopsy.

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Optical Coherence Tomography
Non-invasive imaging technique that uses near-infrared light waves for the cross-sectional
images containing subsurface tissue information.
OCT produces high resolution images approaching the resolution of a microscopy (up to
2µm) and a maximum imaging depth of 2-3mm.
OCT discriminates normal bladder mucosa from bladder cancer based upon qualitative
analysis of the images: normal mucosa is uniform and the bladder walls are clearly
delineated based upon their different backscattering capacities versus bladder cancer
increased the backscattering producing heterogeneity.
OCT probe can be inserted through the working channel of a cystoscope and provide real-time
identification of bladder tumors.
Methods for resection:
Monopolar/bipolar fulguration : bipolar electrocautery system has been introduced to reduce
the risk of complications (e.g., bladder perforation due to obturator nerve stimulation)
Cold cup biopsies
Laser fulguration following cold cup biopsy: preferred for small, Ta LG/G1 tumors on
office basis. Bladder and Prostate Biopsies:
Biopsies of any suspicious areas are an important part of a complete evaluation. The use of random biopsy to
identify CIS in otherwise normal appearing mucosa remains controversial. May and colleagues (2003) performed
random biopsies in high-risk patients and found that the results were positive in 12.4% and altered treatment in
7%. European Organisation for Research and Treatment of Cancer (EORTC) retrospective review
10% of random biopsy specimens were positive (3.5% CIS) and concluded that such biopsies were
not warranted.

The current consensus is that random biopsies are not indicated in low-risk patients (i.e. those with
low-grade papillary tumors and negative cytology).The risk of prostatic urethra- or duct involvement is
higher (a) if the tumour is located on the trigone or bladder neck, (b) in the presence of bladder CIS
and (c) multiple tumours. According to EUA, in patients with positive cytology, but negative
cystoscopy, exclude a Upper tract urothelial cancer, CIS in the bladder (random biopsies or
Photodynamic-guided biopsies) and tumour in prostatic urethra (prostatic urethra biopsy).
STEPS of TURBT

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Pathology Reporting
The pathological report should specify:
tumour location,
tumour grade,
depth of tumour invasion,
presence of CIS, and
Whether the detrusor muscle is present in the specimen.
Presence of LVI or unusual (variant) histology

Restaging TURB
The Vanderbilt University group reporte d a 64% risk of under staging T1 lesions when muscle was absent,
compared with 30% when muscle was present in the specimen. In a review, Miladi and co-workers (2003) found
that a second TURBT detected re sidual tumour in 26% to 83% of patients. The potential for under staging high-
risk disease ranged from 18% to 3 7% (Amling et al, 1994).Herr (1999) reported that a second resection
changed treatment in one third of patients. Grimm et al, 2003, and Sfakianos et al, 2014, showed increased
survival and decreased recurrences in patient who underwent repeat TURBT in T1 and high grade NMIBC. The
consensus is that patients with pT1 and many high-grade Ta tumours merit repeat resection.

EAU guidelines: Perform a sec ond TURB in the following situations:

After incomplete initial TURB;
If there is no muscle in the specimen after initial resection, with the exceptio n of TaG1
tumours and primary CIS;
In all T1 tumours;
In all G3 tumours, excep t primary CIS.
Timing of Repeat TURBT: Wit hin 2-6 weeks after initial resection. It should inclu de resection of
the primary tumour site.

RISK STRATIFICATION (EORTC RISK TABLE):

To facilitate treatment recommendatio ns it is important to categorise patients into risk groups. Based on
available prognostic factors and in particular data from the EORTC risk tables, patients are stratified in
these risk groups:

Treatment recommendation s in Ta, T1 tumors and CIS according to risk stratification

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Intravesical Therapy
It can be of two types:
Intravesical chemotherapy
o Thiotepa
o Mitomycin
o Doxorubicin and its derivatives

Intravesical immunotherapy
BCG
Interferon

To prevent tumor recurrences following TURBT

To prevent possible recurrences because of Iatrogenic implantation
To treat known existing tumor in case of CIS
May also treat undetected existing disease.
Except few studies for BCG, most of the studies failed to show effect on progression of disease.
INTRAVESICAL BCG
Live attenuated strain of Mycobacterium bovis is used.
MECH OF ACTION:
Induces a strong cell mediated cytotoxic immunologic host response.
Release of interleukins and other cytokines.
TIMING OF THERAPY: 2-4 weeks after tumor resection (preceded by urine analysis)
DOSAGE: Reconstituted vaccine in 50 ml saline through urethral catheter. Solution to be
retained for 2 hour post instillation. To reduce BCG toxicity, instillation of a reduced dose was
proposed. CUETO study and EORTC study showed no overall difference in efficacy between
full dose and one third dose but higher recurrence and lower toxicity in one third doses.
SCHEDULE:
Induction schedule: 6- weekly doses are given.
Maintenance schedule: no standard schedule
EORTC trial showed 1 yr maintenance schedule for low to intermediate risk tumor and 3
yr maintenance therapy for high grade tumor.
In a RCT of 1,355 patients, the EORTC has shown that when BCG is given at full dose, 3
years’ maintenance (three-weekly instillations 3, 6, 12, 18, 24, 30 and 36 months) reduces the
recurrence rate compared to one year in high- but not in intermediate-risk patients.
For high-grade T1 lesions or CIS, maintenance therapy has proven superior in multiple
studies (Palou et al, 2001).

Contraindications to Intravesical BCG

Absolute:
Immunosuppressed and imunocompromised patients
During the first 2 weeks after TURB.
In patients with visible hematuria(intravasation risk)
After traumatic catheterization (intravasation risk)
In patients with symptomatic UTI
Total Incontinence ( patient will not retain agent)

Relative:
Liver disease (precludes isoniazid treatment if sepsis occurs)
Poor performance status
Advanced age
Personal history of tuberculosis (risk theorized but unknown)

No/Insufficient evidence on potential contraindications:

Patient with prosthetic materials.
Ureteral reflux.
Anti-tumor necrosis factor medications(theoretically predispose to BCG sepsis)

BCG Toxicity
BCG intravesical treatment is associated with more side effects compared to intravesical
chemotherapy. Serious side effects are encountered in < 5% of patients and can be treated effectively.
Maintenance schedule is not associated with an increased risk of side effects compared to an
induction course. Side effects requiring treatment stoppage were seen more often in the first year of
therapy. Major complications appear after systemic absorption of the drug.

204
BCG Failure
The following categories are recognized as BCG failure:

205
Interferons
Interferons have multiple antitumor activ ities including inhibition of nucleotide synthesis, up regulation
of tumor antigens, anti-angiogenic properties and stimulation of cytokine release with enhanced T- a nd
B-cell activation and enhanced natural killer cell activit y. It is usually given as100 million units, although
optimal dose and administration schedule have yet to be d etermined.IFN as a solitary agent is more
expensive and less effective than BCG or intravesical chemotherapy. As a prophylactic agent, IFN alone
demonstrated r ecurrence rates that were inferior to those of BCG alone. It has been found to be
effective in patients in whom BCG has failed (15% to 20% complete response).
Several trials have investigated the com bination of BCG and IFN. They suggested the potential superiority of
the combination or the possibility of d ecreasing the dose of BCG, which may reduce side effects. Initial
pioneering work by O’Donnell and colle agues (1999) reported a 63% disease-free rate at 1 2 months and 53%
at 24 months with use of combination therapy.CIS patients in whom an induction course of BCG failed the
combination of low-dose BCG and IFN produced a 45% durable response at 2 years. In CIS and BCG naïve
cases, the BCG and IFN combination treatment resulted in 59% disease-free status at 24 m onths.
Intravesical Chemotherapy
Thiotepa, doxorubicin and its derivative s and Mitomycin C (MMC) are most commonly used
chemotherapy agents. Induction therapy using chem otherapeutic agents when instilled within 6 hou rs
of TURBT has demonstrated a clear impact on rec rrence rate. The risk of BCG infectious serious
complications is nonexistent with chemotherapy. The role of chemotherapy in the adjuvant setting is
less clear compared with the efficacy of BCG. Hence, I/V chemot herapy is useful in low to intermediate
risk NIMBC. Currently, there are no indications for the use of chemothera py agents in high grade
bladder cancer. There is n o clear evidence of an impact on progression. Combinations of various
chemotherapeutic agents and chemotherapy combined with BCG have shown no major benefit.

MITOMYCIN C
Mitomycin is the most commonly used i ntravesical chemotherapeutic agent. Mitomycin has an
established role as a single intravesical administration following resection of low risk non-muscle
invasive bladder cancer. Mitomycin also has been used as an adjuvant given as multiple treatments
following T URBT. The optimal volume of administration and dwell time has not been definitively
established. An "optimize d" regimen using a decreased volume in which 40 mg is instilled in 20 cc, in
which urine volume was decreased by dehydration and complete bladder emptying, and in whic h the
urine was alkalinized to stabilize the drug was demonstrated to be superior to the administration of 20 m
g diluted in 20 ml volume in a randomized tria l using six weekly instillations of Mitomycin.

THIOTEPA
Thiotepa was the first intravesical agen to be used for non-muscle invasive bladder cance r and is one of
the few actually approved for use in the U nited States for intravesical administration by the FDA.
However, it is seldom used because of its side effect profile and risk for late complications.
206
A randomized trial conducted by the National Bladder Cancer Collaborative Group showed that intravesical
Thiotepa (30 or 60 mg) was associated with a significant reduction in recurrence rate. Ho wever, it can cause
irritative voiding symptoms in up to 69 percent of patients. Because of its relatively small mo lecular weight
(186 Daltons), thiotepa is absorbed systemi cally, and the incidence of myelosuppression may be as high as 54
percent. Furthermore, thiotepa is a pot ent carcinogen and has been linked to the develop ment of secondary
leukaemia in patients treated for non-muscle invasive bladder cancer.

NOVEL DRUGS
Gemcitabine and the taxanes (Paclitaxel and Docetaxel) have demonstrated activity agains t metastatic
bladder cancer (Calabro and Sternberg, 2002).
These drugs have demonstrated reduction of recurrence of 39% to 70% including modes t efficacy in
heavily pre-treated BCG-refractory patients (Ma ymi et al, 2004; O’Donnell, 2005). However, current
published data are limited to preclinical studies.

REFRACTORY HIGH GRADE DISEAS E (BCG FAILURE)

Few definitions:
BCG refractory- Non improving or worsening disease despite BCG
BCG resistant- Recurrence or p ersistence of lesser degree, stage or grade after an initial course,
which then resolves with further BCG
BCG relapsing - Recurrence afte r initial resolution with BCG
BCG intolerance

EARLY CYSTECTOMY IN NMIBC

For patients with non-muscle invasive bladder cancer, a "prophylactic" or early radical c ystectomy is also a
reasonable treatment option. Patients at highest risk for progression should be considered fo r cystectomy.
Failure to respond to an initial co urse of intravesical therapy is an occasion to recon sider cystectomy.
Failure to respond to a second c ourse is an indication for immediate cystectomy unl ess
contraindicated or the patient chooses to pursue clinical trials or newer proven intravesical
options if evidence builds for their use.

SURVEILLANCE
Cystoscopy is the hallmark of surveillance.
The optimum schedule is undefi ned but may be individualized on the basis of risk.
First cystoscopy should always be performed 3 months after TURB in all patients with Ta, T1
tumours and CIS.
In tumours originally intermediate- or high-risk, recurrences after 10 years tumour-free are not
unusual. Therefore, life-long follow-up is recommended.
The risk of UUT recurrence incre ases in patients with multiple- and high-risk tumour s
The proportion of patients developing upper tract UC after treatment of non–musc le-invasive
disease has been reported as 0.002% to 2.4% over intervals of 5 to 13 years
Although infrequent, the appear ance of upper tract disease is associated with mort ality rates of
40% to 70%.
Patients who have refractory disease are at risk for extravesical recurrence in the prostatic fossa
in approximately one third of cases , 44% of which are fatal.

207
References:

Kassouf,MD. Treatment of primary non-muscle invasive urothelial bladder cancer. Lern er SP(ed). UpToDate 2017.
http://www.uptodate.com.
Babjuk M, Böhle A, Burger M, Capoun O, Cohen D, Compérat EM, Hernández V, Kaasinen E, Palou J, Rouprêt M, van
Rhijn BW. EAU guidelines on non–muscle-invasive urothelial carcinoma of the bladder: update 2016. Euro pean urology.
2017 Mar 31;71(3):447-61.
Hale NE and Deem S. Advances in cystoscopic surveillance of superficial bladder cancer: detection of the invisible
tumor. Med Instrum. 2013; 1:6. http://dx.doi.org/10.7243/2052-6962-1-6.
Jones JS. Non–Muscle-Invasive Bladde r Cancer (Ta, T1, and CIS). Campbell-Walsh urology (Eleventh E d., 2016).

PROSTATE CANCER
- Rishi Nayyar2,S iddarth Yadav1
Introduction

The prostate is derived from the primitive endoderm. It develops from the proliferation of epithelial buds
extending out from the urogenital sinus epithelium. These buds then invade the urogenital sinus mesenchyme
at around 10th week of gestation, a process that is androgen dependent, and give rise to the prostate.
Prostate cancer is the most common n on-cutaneous malignancy amongst men with estim ated life time
risk of disease at 16.72% and estimated life ti me risk of death at 2.57% (1). The African-America ns have
the highest reported incidence as well as death rate s from prostate cancer (1.6 times the white men)
whereas the incidence is lowest amongst the Asians. The me dian age at diagnosis is 68 years and T1c
diseas e (screen detected) account for 60-75% of the cases (1).
Increasing age, African-American ethni ity and family history are well defined risk factors for development of
prostate cancer. Sporadic cancers acc ount for 85% of all the cancers, whereas the rest 15% are familial or
hereditary. Hereditary cancers account for 43% of early (<55yrs) prostate cancers wher eas only 9% of all
cancers that occur by the age of 85yrs. The risk of developing prostate cancer is doubled if one first-line
relative has cancer and if two or more first-li ne relatives are affected, the risk increases by 5 -11-folds [2]. True
hereditary prostate cancer affects 9-10% of patients with prostate cancer and is define d as three or more
affected relatives, or at least two relatives who have developed early-onset disease, i.e. before the age of 55
Patients with hereditary PCa usuall y have an onset around six to seven years earlie r than spontaneous cases,
but do not differ in other ways [3]. Chronic infection is another proposed etiology of p rostate cancer, few studies
show an increased risk of developing prostate cancer by 1.5 times in patients with history of sexually transmitted
disease or prostatitis, wher eas others show mixed results. Genetic basis of p rostate cancer has also been defined.
TMPRSS2 is an androgen responsive prostate specific gene. Its fusio n to genes of ETS family of oncogenic
transcription factors is the most common fusion identified in localis ed prostate cancer. Other than these well
defined risk factor s, androgens, oestrogens, insulin like growth factors, sexual activity and dietary fat content are
also thought to alter the risk of prostate cancer, although the association is weak.
5-alpha reductase inhibitors have a pote ntial benefit in preventing or delaying the developm ent of CaP
(cancer prostate). But this potential benefit is ab out 25% reduction in incidence of only of Gleason 6 cancer,
and there is no reduction in higher Gleason score disease. This small benefit must be weighed again st
treatment-related side effects as well as the potential increased risk of high-grade CaP [4,5]. Thus none of t he
available 5-ARIs have been approved for this indication. Various other medications such as NSAIDS, selenium,
Vitamin E, soy, lycopene and selective oestrogen rece ptor modulation were tried but none showed a sig
nificant reduction in prostate cancer risk thus are not currentl y recommended as prophylaxis.

208
Pathology
Mc Neal divided prostate into 4 anatomic zones. Peripheral zone has 75% of the prostates glandular
elements and harbours 70% of the cancers. Transitional zone has 5% of prostate glandular elements
but harbours 20% of cancers. Central zone has 25% of prostate glandular elements but harbours only
5% of cancers. Anterior fibromuscular area has 30% of prostatic mass, no glandular elements and
rarely is the site of cancer (1). Prostatic adenocarcinoma are mostly bilateral (70% cases) and
multifocal in more than 85% of cases (1). Prostatic cancer has propensity to spread along the nerves
(perineural invasion) but this finding does not portend poor prognosis because it merely represents
extension of a tumour along the plane of decreased resistance. Invasion into lymphatic or vascular
structures increases the chances of recurrence and thus indicate poorer prognosis.
Prostatic adenocarcinoma is graded according to modified Gleason grading system based on the glandular
pattern of the tumor as identified under low magnification (Figure 1). Then based on the two most
predominant Gleason patterns, a Gleason score is calculated. For Gleason score, the primary Gleason
grade (most extensive grade) and the secondary pattern (second most prevalent grade) are identified and
their assigned Gleason grade (1 to 5) is added to get the Gleason score out of 10. If only one grade is
present, the primary grade is doubled to get the Gleason Score. This is the usual practice for radical
prostatectomy specimen, however for prostatic biopsy specimen the predominant Gleason grade and the
highest grade are added to get the Gleason Score. This is done to overcome the sampling limitations
inherent to the needle biopsy procedure. Gleason pattern 1 and 2 are not reported on needle biopsy
specimens thus the lowest score for a patient reported as adenocarcinoma is 6 (3+3).
Gleason grouping is new concept introduced that further classifies Gleason score into 5 groups that is
3+3, 3+4, 4+3, 4+4 and a fifth group that contains 4+5 and 5+4. Grouping has prognostic significance
and is used to direct treatment strategy

Diagnostic evaluation
Screening and early detection
Screening is different from early detection or opportunistic screening. Population or mass screening is defined as
the systematic examination of asymptomatic men (at risk) and is usually initiated by health authorities. In contrast,
early detection or opportunistic screening consists of individual case findings, which are initiated by the person
being screened (patient) and/or his physician. Testing all adult males in community is screening whereas testing
males presenting to outpatient department with lower urinary tract symptoms is early detection. Screening of
prostate cancer is most controversial topic in urologic literature. On one end of spectrum is the proposed
reduction in cancer prostate mortality rate that is still not supported by level 1 evidence and on the other end is
over detection and over treatment. Thus currently, all major guidelines recommend a shared decision making for
SPSA testing. The patient should be counseled about the potential risks and benefits of SPSA screening and
should take an informed decision about it. Also, physicians should not offer SPSA as a screening test to patients
with less than 10 years of life expectancy. The recent European urological association guidelines for prostate
cancer screening are depicted in Table 2.

Clinical diagnosis
Prostate cancer presents with lower urinary tract symptoms indistinguishable from benign prostatic
hyperplasia. As most cancers are located in the peripheral zone, a nodule may be palpable on digital rectal
examination. Cancers detected on rectal examination have greater chances of being of higher Gleason
grade. SPSA on the other hand is a better predictor of presence of cancer and thus invariably picks up
lower risk disease also. It is a continuous parameter, with higher the value greater the risk of cancer.
Clinically a cut off of 4 ng/ml is used as a trigger for biopsy, but various other cutoffs such as age specific
cut off, PSA density or the free PSA levels may also be used. A free/total PSA ratio < 0.10 suggests cancer
whereas a ratio >0.25 is indicative of benign disease. Other newer markers such as PHI (prostate health
index - combining free and total SPSA and the - 2pro PSA), urinary PCA 3 or the 4K (4 kallikrein score) may
also be used to trigger the biopsy in patients with SPSA in `grey zone` between 4-10 ng/ml. Trans-rectal
ultrasonography guided prostate biopsy is the standard of care and 12 cores (6 from each lobe of prostate)
of prostatic tissues are taken and subjected to histopathology. A repeat biopsy may be performed in
patients with a previous negative biopsy and persistently high PSA, extensive (>2 cores) high grade
prostatic neoplasia intra-epithelial neoplasia or atypical acinar proliferation on the first biopsy report. A
repeat biopsy should focus on areas where previous biopsy showed suspicious findings, target transitional
and anterior fibromuscular areas and should also include the standard 12 core map of prostate. A saturation
biopsy may be used if suspicion is high, which takes 20-24 cores in total mapping all zones of prostate.

Imaging
Ultrasonography, abdominal or transrectal, cannot accurately detect malignant nodules. Most of the cancer
nodules are either hypo-echoic or iso-echoic to rest of peripheral zone of prostate and a hypo-echoic lesion has
only 17-57% of chance of being malignant nodule. Multi-parametric MRI (T1, T2, with either dynamic contrast
enhancement or diffusion-weighted imaging) has an excellent diagnostic accuracy for clinically significant (GS 7
or more) cancers. It can locally stage the disease (T stage) as well and stage the pelvic lymph nodes.

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mpMRI can detect tumors in anterior fibromuscular area and central zone which are usually missed on prostate
biopsy and thus is a valuable imaging tool before a repeat biopsy, although its role before the first biopsy is still
being defined. Inter-reader variability in reporting of prostate cancer remains a concern and use of PIRADS
(prostate imaging reporting and data system) is recommended to improve accuracy. Data from a mpMRI can be
loaded on a MRI-TRUS fusion system and can be used to direct prostate biopsy cores during TRUS guided
prostate biopsy for a more accurate sampling of prostatic lesion. This MRI-TRUS fusion biopsy is considered as
state of art system that converts a `blind` prostatic biopsy sampling procedure in a more `targeted` approach and
still avoids the cost and technical implications of in-bore MRI biopsy systems, in which biopsy are performed with
the patient inside the MRI gantry and requires costly MRI safe biopsy needles and is difficult to perform for the
operator because of space crunch inside the gantry.
GaPSMA PET scan is a recent addition to diagnostic armamentarium for the treating urologist. PSMA (prostate
specific membrane antigen) is transmembrane protein that is over-expressed in CaP. Humanised monoclonal
antibody against the extracellular domain of PSMA is combined to Gallium 68 and is able to specifically pick up
site of prostate cancer both locally within the prostate and at metastatic sites. The exact place of Ga-PSMA PET
scan is still being defined, but is commonly used for staging patients with equivocal finding on MRI or Bone scan
or to localise the disease in patients with biochemical relapse after radical prostatectomy.
TRUS guided prostate biopsy
Raised SPSA or abnormal DRE form the indication for prostate biopsy, which is performed under trans-
rectal USG guidance. The USG fails to identify specific lesions but gives an accurate picture of size and
shape of gland thus helps to uniformly distribute the cores in a `blind` biopsy procedure. Also, any hypo
echoic lesion in PZ should be specifically biopsied. Previously a sextant (6 core biopsy) was considered
adequate, but a 10-12 core needle biopsy better maps the prostate and is the current standard of care. On
the first biopsy, adequately sampling of prostates peripheral zone by uniformly distributing the core
placement in accordance to prostatic anatomy and directing the core laterally in direction of PZ provides
greatest yield. Instead of sampling of whole of prostate, MRI-TRUS fusion biopsy allows to take few directed
cores from specific suspicious areas thus increasing the yield for clinically significant cancers. However,
despite the targeting, MRI-TRUS fusion biopsy has a false negative rate of 5-10% and studies are underway
to better define its place in biopsy naive patients. MRI-TRUS fusion biopsy is best suited for patients who
are already on active surveillance and these with previously negative biopsies.

Clinical Staging
DRE, SPSA, biopsy findings and bone scan are used to guide clinical decisions and more extensive
local staging in form of mpMRI is obtained in patients considered eligible for local treatment. mpMRI
has low sensitivity (20-80%) to detect extra-prostatic extension or seminal vesicle extension but has
high specificity (60-100%) (6). Thus, few centres don't consider mandatory cross sectional imaging as
a part of pre-operative workup. However, patients that fall in high risk category need pelvic imaging to
rule out nodal metastasis. Either CT or MRI can be used to stage pelvic nodes but both have a low
sensitivity of <50% (7). Metastatic staging in form of bone scan is recommended in patients with T1 &
SPSA >20ng/ml, T2 and SPSA > 10ng/ml, T3, T4 and those with symptoms of bone pain (7).
TNM staging of cancer prostate is given in Figure 3. Based on TNM, SPSA, Gleason score a risk
classification was proposed by D`Amico which has been later adopted and modified by EAU and NCCN.
This risk classification categorises patients into low, intermediate and high risk group and helps in directing
treatment options. The low risk has been further classified into very low and low and high risk has been
further classified into high and very high risk. Risk groups adapted by NCCN have been shown in Table 4.
Disease management
Prostate cancer management is complicated by its high prevalence, low cancer specific mortality rates, slow
growth and its indolent nature is some patients. It was estimated that prostate cancer specific mortality occurs
about 13 years after the diagnosis of localised disease and about 5 years after diagnosis of metastatic disease
(1). However, this indolent appearing scenario is complexed by a small subgroup of patients that present
with rapidly progressing and fatal disease and another subset in which it never progresses. Thus, it’s a
challenge for the treating physician to balance harms of over treatment from those of under-treatment.

Deferred treatment
Many men will not benefit from immediate definitive treatment of cancer prostate and thus are
candidates for deferred treatment. Deferred treatment is a broad term that encompasses watch full
waiting and active surveillance, both of which are conceptually different.

Active surveillance
It aims to reduce over treatment by achieving correct timing of curative treatment. Patients with good
life expectancy and low burden low risk disease are suitable candidates. They are kept under close
observation and a curative treatment is offered at 1st sign of progression of disease. Patients are
under a specific follow up schedule and curative intervention such as radical prostatectomy or
radiotherapy is offered as first sign of progression.
Active surveillance (AS) aims to reduce over treatment in patients with clinically confined low risk
cancer prostate without relinquishing curative treatment.
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Thus young patients with life expectancy of > 10 years and low risk disease that is GS 6 or 7 (3+4 only), <2-3 cores
+, <50% of core involvement, clinically T1c or T2a and SPSA <10ng/ml are included (7, 8). These patients get
regular SPSA and DRE examination no frequent than 6 monthly. Surveillance biopsy are also performed no
frequent than 1 year or as and when the DRE changes, SPSA rises or MRI suggests aggressive disease. Cancer
progression is usually defined as change in Gleason score, primary Gleason pattern 4 or 5, increase in number of
positive cores or increased % core involvement. Other parameters such as changes in SPSA or PSA density are
weak and questionable. Cancer progression or patients request are 2 indications to shift the patient from active
surveillance to active treatment such as radical prostatectomy or radiotherapy.
The advantages of AS are that about 2/3rd men included in AS can actually avoid treatment of small
indolent CaP and its untoward effects. But the main disadvantage is that in a small unknown
percentage of patients, the disease may progress and the window of curative treatment may be lost.

Watchful waiting
It refers to conservative management for mostly older or higher risk patient with limited life
expectancy. Patient may not be kept under regular follow up and palliative treatment is undertaken at
development of local or systemic symptoms. Only palliative procedures such as TURP, hormonal or
radiotherapy are under taken that too at development of symptoms with a palliative intent. The
differences between watchful and active surveillance are enumerated in Figure 5.
The rationale for watchful waiting is that CaP is often diagnosed in older men with comorbidities and often
progresses slowly. In such patients, the competing causes of mortality are more important than cancer prostate
mortality itself. Patients with <10 year expected survival and localised cancer prostate are ideal patients for
watchful waiting. There is no need for regular investigations or examination or a repeat biopsy. Patient presents
back to treating physician when he develops symptoms such as lower urinary tract symptoms or bone pain and is
started on palliative androgen derivative therapy at that time. Other interventions include channel TURP or
palliative radiotherapy for painful bony metastasis. Patients with shorter life expectancy but high risk or metastatic
disease are not good candidates for watchful waiting and require careful assessment as the disease may progress
quickly and are better suited for immediate hormonal therapy.
Radical Prostatectomy
Radical prostatectomy (RP) involves removal of entire prostate with both seminal vesicles and vas upto the
ampullary part along with sufficient surrounding tissue to achieve a negative margin. This is combined with
bilateral pelvic lymph node dissection in patients with intermediate and high risk disease. RP is a major
surgery with significant peri-operative risks and patients with severe co-morbidities or these with life
expectance <10 years are less likely to benefit. RP has been shown to improve overall survival and cancer
specific survival as compared to conservative treatment for localised cancer prostate (7).
Open radical prostatectomy can be performed with via the retro-pubic route or perineal route. In the last two
decades, minimally invasive RP ie laparoscopic and robotic radical prostatectomies are displacing open
procedures as the standard of care. Currently 80-90% of radical prostatectomy are performed robotically.
Robotic surgery has lower peri-operative morbidity and enhanced functional recovery as compared to open
surgery along with equal if not better oncologic and functional outcomes. Surgical expertise plays an
important role in functional outcomes after radical prostatectomy and with increasing experience, the
margin positivity rates reduce and continence and functional outcomes improve. In intermediate and high
risk cases, an extended pelvic lymph node dissection is recommended, which includes removal of
obturator, internal iliac, external iliac and common iliac nodes upto the ureteral crossing.
Overall, the outcomes after robotic radical prostatectomy are assessed as either trifecta or pentafecta
outcomes. Trifecta includes positive surgical margin, urinary continence and erectile function. Pentafecta
further adds biochemical relapse rates and peri-operative morbidity to trifecta outcomes. Trifecta outcomes
of robotic radical prostatectomy are encouraging, with a positive margin rate to 15-20% (increases with
increasing T stage of disease), 80-90% continence rates and 50-60% erectile function rates (9). These
functional outcomes are also influenced by pre-operative parameters such as age, pre-op continence, pre-
operative erectile function, nerve sparing during the procedure, previous history of TURP etc.
Presence of margin positivity, seminal vesicle invasion or extra capsular invasion on post radical
prostatectomy histology suggests adverse pathologic findings and adjuvant radiotherapy can be
instituted either immediately or at SPSA recurrence.

Radiotherapy
Current concepts in prostatic radical radiotherapy (RT) revolves around 3D CRT, IMRT, IGRT. 3D CRT is 3
dimensional conformal radiotherapy. First a cross sectional imaging is performed and data is loaded onto
the RT machine that conforms the radiotherapy beam in a way to deliver maximal dose to target tissue and
preserves the healthy tissue thus reducing side effects. IMRT, intensity modulated radio-therapy, with use
of multi leaf collimators, automatically and continuously adapts to the contours of target volume and the
intensity of each beam is modulated in a way that it delivers maximal dose to target volume and spares the
surrounding tissue. The main benefit of IMRT is in rectal sparing during RT. IGRT, image guided RT, is a
part of both 3D CRT and IMRT and includes placing a target, either in form of fiducial seeds into prostate or
a catheter, that allows for continuous identification of the target and better accuracy even when the target is
moving for example with respiration or bladder filling, thus reducing damage to healthy tissues.
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These techniques allow for dose escalation which is the corner stone for current day curative radiotherapy.
A dose of 74-80Gy is considered curative for CaP and provides oncologic outcomes similar to radical
prostatectomy. Neo-adjuvant/ adjuvant or concomitant hormonal therapy is added to RT in intermediate risk
(for 4-6months) and high risk (for 2-3years) patients to shrink the prostate and improve efficacy of RT.
Oncologic outcomes of RT and RP are similar for all risk groups patients, thus all patients with
localised CaP are offered a choice between RT and RP.
Despite the equal oncologic potential, the side effect profile is very different with incontinence and
erectile dysfunction being main problems after RP and bladder and bowel complaints that develop few
years after RT. Brachytherapy has also been utilised in CaP. Low dose rate (LDR) brachytherapy is
used in patients with low risk disease with <50gm prostates with a curative intent. In LDR
brachytherapy, Iodine 125 or palladium 103 permanent implants can be implanted into the prostate via
a perineal template. An advantage of LDR brachytherapy is that lower radiation is given to rectum
thus, bowel complications are lesser but a cost of higher urinary complications.
High dose rate (HDR) brachytherapy used Iridium 192 needles which are temporarily placed into to
prostate and deliver a 45Gy to the prostate and are mainly used to as a boost in addition to EBRT.
Newer modalities
Cryotherapy: Cryo uses freezing technique to cause cellular death by causing dehydration, protein
denaturation, direct rupture of cellular membranes due to ice crystals and vascular stasis. Initial
machines used liquid nitrogen, but current 3rd generation systems utilise argon gas for cooling.
Pressurised argon gas when expands causes rapid cooling by Joule-Thompson effect.
Cryo needles are placed under TRUS guidance and a urethral warmer is also placed. Two freeze-thaw
cycles are utilised and a temperature of -40 C is achieved during freezing phase. The tissue should be
allowed to cool as slowly as clinically possible and usually Helium gas which warms on expansion is
used to achieve thawing. 2 freeze thaw cycles achieves adequate necrosis, and the ice ball formation
and freezing can be monitored under USG under real time.
High-intensity focused ultrasound of the prostate: HIFU consists of focused USG waves that cause
tissue damage by thermal and mechanical effects. It heats up the tissue above 65 C thus inciting
coagulative necrosis. But it is a slow process and to ablate 10g of tissue it takes one hour.
Risk-group wise treatment of localised CaP
Low risk cancer prostate (T1/2a N0 M0; GS 6; SPSA <10 ng/ml)
Currently stage T1c is represents 40-50% of new CaP cases and incidence of localised cancer prostate is
increasing (10). Use of SPSA screening has provided a lead time bias of about 10 years (10). Patients with
life expectancy of <10 years are best suited for watchful waiting. For those > 10 years life expectancy, Active
surveillance, radiotherapy or radical prostatectomy all are equivalent options. Patients should be counseled
about all the options and their side effects and should make an informed choice.

Intermediate risk cancer prostate (T2b-c N0 M0; GS 7; SPSA 10-20 ng/ml)

If the life expectancy of the patients is less than 10 years, then watchful waiting is advisable. For those with
better life expectance either radical prostatectomy or radiotherapy is recommended. Active surveillance can
only be offered to select group of patients with GS 3+4, T1-2a lesion and SPSA <10ng/ml.

High risk cancer prostate (T3a N0 M0; GS >7; SPSA >20 ng/ml)
Watchful waiting is not recommended for high risk patients. Radiotherapy with 2-3yrs of androgen
therapy or radical prostatectomy is recommended.

Highest risk cancer prostate (T3b-4 N0/1 M0; primary GS 5; >4 cores of GS >8)
Radiotherapy with 2-3 years of hormonal therapy is treatment of choice. Radical prostatectomy can be
offered to select group of patients with resectable disease but the possibility of need of adjuvant
therapy is high. Node positive patients are categorised as metastatic, either RT+ hormonal therapy or
hormonal therapy are recommended options.

Follow up and adjuvant treatment

Post treatment patients are followed up with general examination and SPSA levels. After radical
prostatectomy, a SPSA of >0.2 ng/ml that has been confirmed by a repeat value is defined as
biochemical failure. Defining biochemical failure after RT is more difficult, and a rising SPSA value
2ng/ml above the nadir value, irrespective of the nadir value.
After the diagnosis of biochemical relapse, repeat investigations may be performed in form of MRI pelvis or Ga-
PSMA PET scan to locate the site of recurrence and appropriate treatment can be instituted accordingly.
Metastatic cancer prostate
The median survival of newly diagnosed metastatic CaP is 42 months, but this is heterogenous population.
These patients are primary treated by systemic therapy with a palliative intent.
In patients deemed fit, a combination of androgen deprivation therapy along with docetaxal based
chemotherapy is started, where as hormone therapy alone is recommended for patients deemed unfit
for chemotherapy.

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Hormone therapy or androgen deprivation therapy is standard of care. There are 2 common ways of
achieving castration, either surgically by orchidectomy or medically, both are equally efficacious.
Surgical castration is achieved by sub capsular orchidectomy. Medical castration utilised LHRH
analogues (leuprolide, triptorelin & goserelin) administered as I/M or S/C at 1, 3 or 6 monthly intervals.
LHRH antagonists (degarelix) are also available that avoid the initial flare associated with LHRH
analogues. Maximal androgen blockade (combined androgen blockade) blocks adrenal androgen
production in addition to testicular androgen production by adding bicalutamide (antiandrogen) to
treatment and offers an additional 5% benefit in patients with extensive metastasis.
After initiation of treatment, patients remain under regular followup with serial SPSA measurement. A
rise in SPSA greater than 2ng/ml confirmed on a repeat value indicates development of castrate
resistant cancer prostate and 2nd / 3rd line medications such as abiraterone acetate, enzalutamide,
nilutamide, ketonazole, phytoestroges, docetaxal based chemotherapy, cabazitaxal based
chemotherapy and best supportive care are offered.
References
Abouassaly R, Thompson IM, Platz EA and Klein EA. Epidemiology, etiology and prevention of prostate cancer. Campbell
10th edition Saunders Elsevier.
Jansson KF, Akre O, Garmo H, et al. Concordance of tumor differentiation among brothers with prostate cancer. Eur
Urol 2012 Oct;62(4):656-61.
Hemminki K. Familial risk and familial survival in prostate cancer. World J Urol 2012 Apr;30(2):143-8.
Andriole GL, Bostwick DG, Brawley OW, et al; REDUCE Study Group. Effect of dutasteride on the risk of prostate cancer.
N Engl J Med 2010 Apr;362(13):1192-202.
Thompson IM, Goodman PJ, Tangen CM, et al. The influence of finasteride on the development of prostate cancer. N
Engl J Med 2003 Jul;349(3):215-24.
de Rooij M, Hamoen EH, Witjes JA, Barentsz JO, Rovers MM. Accuracy of Magnetic Resonance Imaging for Local Staging of
Prostate Cancer: A Diagnostic Meta-analysis. Eur Urol. 2016;70:233-45
EAU-ESTRO-SIOG guidelines on prostate cancer 2016.
NCCN guidelines for prostate cancer 2017.
Novara G, Ficarra V, D'Elia C, Secco S, Cavalleri S, Artibani W. Trifecta outcomes after robot-assisted laparoscopic
radical prostatectomy. BJU Int 2011;107:100-4
Klotz L. Active surveillance for prostate cancer : trials and tribulations. World J Urol 2008;26:437-42

Figure 1: Gleason grading system for prostate cancer

Table 2: EAU 2017 guidelines on screening for prostate cancer

Do not subject men to prostate-specific antigen (PSA) testing without counselling them on the potential risks and benefits.

Offer an individualised risk-adapted strategy for early detection to a well-informed man with a good performance
status and a life-expectancy of at least ten to fifteen years.

Offer early PSA testing in well-informed men at elevated risk of having PCa:
men > 50 years of age;
men > 45 years of age and a family history of PCa;
African-Americans > 45 years of age;
men with a PSA level of > 1 ng/mL at 40 years of age;
men with a PSA level of > 2 ng/mL at 60 years of age.

Offer a risk-adapted strategy (based on initial PSA level), with follow-up intervals of two years for those initially at risk:
men with a PSA level of > 1 ng/mL at 40 years of age;
men with a PSA level of > 2 ng/mL at 60 years of age;
Postpone follow-up to eight years in those not at risk.

Decide on the age at which early diagnosis of PCa should be stopped based on life expectancy and performance
status; men who have a life-expectancy of < 15-years are unlikely to benefit.

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 Figure 3: TNM classification for cancer prostate

Figure 4: N CCN 2017 risk groups of prostate cancer

Definition Fea tures

Very low risk T1c

SP SA <10ng/ml
Gle ason Score 3+3
<3 cores +, <50% disease in each core
PS A density <0.15

Low risk T1-T2a

Gleason score 3+3
SP SA < 10ng/ml

Intermediate risk T2b -T2c

Gle ason score 7
SP SA 10-20ng/ml

High risk T3a

Gleason score 8
SP SA >20ng/ml

Very high risk T3b -T4

Pri mary Gleason 5
>4 cores with Gleason 8-10

Figure 5: Differences between active surveillance and watchful waitin g

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 ERECTILE DYSFUNCTION
-Dr. Iqbal Singh

FUNCTIONAL ANATOMY OF THE PENIS (1)

The penis grossly consists of three cylindrical structures: the paired corpora cavernosa and the
corpus spongiosum (which contains the urethra). This structure complex is surrounded by a loose
subcutaneous layer and skin.

Figure 3: ANATOMY OF PENIS

Tunica Albuginea
The tunica albuginea is a tough fibrous layer of connective tissue which encloses the corpora
cavernosa. It provides flexibility and at the same time, rigidity and tissue strength to the penis. It has
two layers: Inner-layer bundles support and contain the cavernous tissue. These are oriented
circularly. Outer-layer bundles are oriented longitudinally, extendingfrom the glans penis to the
proximal crura and insert into the inferior pubic rami but are absent between the 5 o'clock and the 7
o'clock positions. The tunica is composed of elastic fibres that form an irregular, latticed network
which is covered by collagenfibres, which are mostly of type I fibrillary collagen and a few type III (2).
Elastin is stretchable up to 1.5 times its original length. This is responsible for expansion of tunica albuginea,
resulting in increase in penile length. At the same time collagen provides great tensile strength to the tunica. The
fundiform and suspensory ligaments form external support of the penis. The fundiform ligament arises from
Colles fascia and is lateral, superficial, and not adherent to the tunica albuginea of the corpora cavernosa. The
suspensory ligament arises from Buck fascia and consists of two lateral bundles and one median bundle, which
circumscribe the dorsal vein of the penis. Its main function is to attach the tunica albuginea of the corpora
cavernosa to the pubis, and it provides support for the mobile portion of the penis (3).

Corpora Cavernosa, Corpus Spongiosum, and Glans Penis

The corpora cavernosa consist of a pair of spongy cylindrical structures enveloped by tunica
albuginea. They take origin from the under-surface of the ischio-pubic rami as crura and merge under
the pubic arch and remain attached up to the glans. The septumbetween the two corpora cavernosa is
incomplete in men but is complete in some species such asdogs.
Each corpus cavernosum consists of arrangement of larger sinusoids in the centre and smaller in the
periphery. When the penis is flaccid, blood slowly diffuses from the central to the peripheral
sinusoids, and the blood gas levels are similar to those of venous blood. During erection, there is
sudden influx of arterial blood simultaneously to both the central and the peripheral sinusoids which
changes the intra-cavernous blood gas levels to those of arterial blood (4).
Apart from the larger size of sinusoids, there is not much difference in the structure of the corpus
spongiosum and glans as compared to that of the corpora cavernosa. The tunica covering over
corpus spongiosum lacks longitudinal layer and hence is relatively thin. Tunica is absent in the glans.

Arteries
Penis is supplied by the internal pudendal artery, which is a branch of the internal iliac artery. Three
patterns of penile arterial supply have been recognized:
Type I- arising exclusively from internal pudendal arteries;
Type II- arising from both accessory and internal pudendal
arteries; and Type III- arising exclusively from accessory
pudendal arteries. (5) Veins
Peripheral sinusoids lying just underneath the tunica albuginea of the corpora cavernosa and corpus
spongiosum leads to tiny venules which form subtunical venous plexus within the trabeculae situated
between the tunica and the peripheral sinusoids. They finally exit the penis as emissary veins.
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MECHANISM OF ERECTION
Penile erection occurs as a result of neurotransmitter release from the cavernous nerve terminals
following sexual stimulation. This leads to relaxation of smooth muscles of corpora cavernosa
and of arteriolar walls, resulting in:
Arteriolar dilatation in the penis;
Enlargement of sinusoids, causing retention of blood;
Decrease in venous outflow secondary to compression of venous plexus between tunica
albuginea and the peripheral sinusoids;
Further reduction in venous outflow due to compression of emissary veins because of stretching of
tunica; and
Rise in oxygen saturation in penile blood (to about 90 mm Hg) and intracavernous
pressure (approximately 100 mm Hg)-“the full-erection phase”. A further pressure increase (to
several hundred millimetres of mercury) can occur with reflex contractions of the ischio-
cavernosus muscles during sexual stimulation-“rigid erection phase”.

NEUROANATOMY AND NEUROPHYSIOLOGY OF PENILE

ERECTION NEUROTRANSMITTERS:
Flaccid state of the penis is a consequence of intrinsic myogenic activity (7); adrenergic
neurotransmission; and endothelium-derived contracting factors such as angiotensin II, PGF2α, and
endothelin-1. Detumescence after erection is due to blockage of NO release, the breakdown of cyclic
guanosine monophosphate (cGMP) by PDEs, and/or sympathetic discharge during ejaculation.
NEUROTRANSMITTER RECEPTOR AND FUNCTION
Neurotransmitter Function
Dopamine D1 and D4 receptor—enhances erection
D2 receptor—enhances seminal emission
Serotonin (5-HT) 5-HT—inhibits sex drive and spinal sexual reflex
5-HT1A—inhibits erection, facilitates ejaculation
5-HT2C—enhances erection
Norepinephrine Enhances sexual function
γ-aminobutyric acid Inhibits erectile signals
Opioids Inhibit penile erection
Cannabinoids Inhibit sexual function
Oxytocin Enhances appetitive and reinforcing effects of sexual
activity
Nitric oxide Mediates erection at paraventricular nucleus
Melanocortins MCR4—enhances erection
Prolactin Suppresses sexual function

Autonomic Pathways:
The sympathetic pathway originates from the T11 to the L2 spinal segments and passes through the
white rami to the sympathetic chain ganglia.
The parasympathetic pathway arises from neurons in the intermedio-lateral cell columns of S2,3&4 sacral
spinal cord segments. The preganglionic fibres pass in the pelvic nerves to the pelvic plexus, where they
are joined by the sympathetic nerves from the superior hypogastric plexus. The cavernous nerves are
branches of the pelvic plexus that innervate the penis. Stimulation of the pelvic plexus and the cavernous
nerves induces erection, whereas stimulation of the sympathetic trunk causes detumescence. (6)
SPINAL REFLEXES INVOLVED IN ERECTION
STIMULATION SPINAL CENTER EFFERENT EFFECT
Noxious, abrupt Sacral motor neurons. Pudendal nerve Bulbo-cavernous reflex
stimulation (motor)
Low-intensity Sacral parasympathetic 1. Pelvic nerves 1. Bladder inhibition
continuous (e.g., neurons and 2. Cavernous nerve and closure of
vibratory, manual) Interneurons. bladder neck
2. Penile erection
High-intensity Sacral motor and Pudendal, pelvic, and Ejaculation
continuous parasympathetic. cavernous nerves
Thoraco-lumbar
sympathetic
Neurons.

RISK FACTORS
Common risk factor categories associated with sexual dysfunction include the following: general
health status, diabetes mellitus, cardiovascular disease, concurrent genitourinary disease, psychiatric
disorders, other chronic diseases, socio-demographic condition, smoking, certain medications,
hormonal factors and endothelial dysfunction.
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CLASSIFICATION OF ERECTILE DYSFUNCTION (8)
Organic
Vasculogenic
Arteriogenic
Cavernosal
Mixed
Neurogenic
III. Anatomic
IV. Endocrinologic

Psychogenic
Generalized
Generalized unresponsiveness
Primary lack of sexual arousability
Aging-related decline in sexual arousability
Generalized inhibition
Chronic disorder of sexual intimacy
Situational
Partner-related
Lack of arousability in specific relationship
Lack of arousability owing to sexual object preference
High central inhibition owing to partner conflict or threat
Performance-related
Associated with other sexual dysfunction (e.g., rapid ejaculation)
Situational performance anxiety (e.g., fear of failure)
Psychological distress or adjustment related
Associated with negative mood state (e.g., depression) or major life
stress (e.g., death of partner)

PSYCHOGENIC VS ORGANIC ERECTILE DYSFUNCTION (9)

PSYCHOGENIC ORGANIC
Sudden onset Gradual onset
Complete immediate loss Progressive
Situational dysfunction Global dysfunction
Waking erections present Waking erections poor/absent

EVOLUTION IN THE MANAGEMENT OF ERECTILE DYSFUNCTION (10)

DIAGNOSTICS TREATMENTS GUIDES
Pre-1970 Psychosexual history Psychosexual therapy Studies of Masters & Johnson
Herbal supplements
1970s Medical and psychosexual history Penile prosthesis International Conferences on
Nocturnal penile tumescence surgery Corpus Cavernosum
testing Penile Revascularization
revascularization
1980s Physical examination Oral medications Goal-directed management
Endocrine evaluation Intracavernous
Penile duplex ultrasonography, pharmacotherapy
DICC Vacuum device therapy
1990s Combined intracavernous Intraurethral NIH Consensus Statement
injection and stimulation pharmacotherapy Process of Care Model
Oral
phosphodiesterase
type 5 therapy
After 2000 Biomarkers of vascular health ? Gene therapy ICUD algorithms (patient-
Neuroimaging ? Stem cell therapy centred approach)
? Tissue engineering AUA Practice Guidelines
(evidence-based approach)

MANAGEMENT PRINCIPLES (10)

Early Detection
In patients who have readily identifiable risk factors are good candidates for screening so that early
diagnosis and better management of individual cases could be achieved.

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Goal-Directed Management
This involves well-informed decision making by the patient so that the patient can choose the best
possible treatment method for sexual dysfunction out of the available modalities, after a thorough
discussion with the treating clinician. Proper counseling of the patient beforehand is essential.

Step-Care Approach
Process of Care Consensus Panel developed a step-wise approach regarding the management of
erectile dysfunction in 1999. It proposed an algorithm consisting of various stages of management
depending upon the individual patient. This ranged from lifestyle modification to surgery.

DIAGNOSTIC EVALUATION
Diagnosis of erectile dysfunction requires a detailed history, preferably taken from patient and
partner, physical examination and proper laboratory tests.
Sexual history – this is essential in order to ascertain the nature, extent and cause of the
specific problem with respect to the patient. The severity of erectile dysfunction can be defined
as mild, moderate or severe, according to the varying extent of loss of penile erection and the
associated interference with sexual activity.
Medical history - The main objective is to explore the role of possibly related or underlying
medical conditions and to identify co-morbidities.
Psychological history - unstable psychosocial circumstances of both intrapersonal and
interpersonal contexts may adversely affect sexual function.
Cardiovascular Risk Assessment Tools - models such as the Framingham Risk Score, which
incorporate cardiovascular risk factors like family history of coronary heart disease, body
mass index, etc provide help in determining the underlying aetiology and also guide in better
management of the patient.
Physical examination - This evaluation consists of basic head to toe examination, assessment of
secondary sexual characteristics and systemic, with a particular focus on the external genitalia.
Laboratory tests – These include routine hemogram and general blood picture, random blood
glucose, lipid and thyroid profiles, serum testosterone level, etc.

SPECIALIZED EVALUATION AND TESTING (11)

a) VASCULAR
Dynamic infusion cavernosometry and cavernosography (DICC)
Intracavernous injection pharmacotesting (ICI)
ICI and colour duplex ultrasound
Arteriography
Computed tomography angiography
Magnetic resonance imaging (MRI)
Infrared spectrophotometry
Radioisotope penography
AUDIOVISUAL SEXUAL STIMULATION (AVSS)
Independent or jointly with vascular testing
With or without: pharmacologic stimulation (oral, ICI)
NEUROPHYSIOLOGIC
Nocturnal penile tumescence and rigidity (NPTR)
Erectiometer/rigidometer
Biothesiometry (vibratory thresholds)
Dorsal nerve conduction velocity
Bulbocavernosus reflex latency
Plethysmography/electrobioimpedance
Corpus cavernosum electromyography (CC-EMG)
MRI or positron emission tomography scanning of brain (during AVSS)

TREATMENT METHODS:
Lifestyle modification – healthy diet, regular exercise, smoking cessation
Medication change – any identifiable drug which has a potential to cause erectile dysfunction
should be stopped.
Psychosexual therapy
Hormonal therapy
Testosterone replacement – I/M, S/C, buccal, oral,
transdermal Dehydrotestosterone
Hyperprolactinemia treatment
Pharmacologic therapies
Oral

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 Phosphodiesterase (PDE) type 5 inhibitors – Sildenafil, Vardenafil, Tadalafil, Avanafil
SILDENAFIL VARDENAFIL TADALAFIL AVANAFIL
Onset of action 15-60 15-60 15-120 15-60
(min)
Half-life (hr) 3-5 4-5 17.5 3-5
Bioavailability 40% 50% N.A. 30%
Fatty food Reduced Reduced No effect Reduced
absorption absorption absorption
All of these may cause headache, gastritis, backache, myalgia and all are
contraindicated with nitrates. In particular, Sildenafil is prone to cause blue vision.
Alpha adrenergic antagonists – Phentolamine, Yohimbine
Dopaminergic agonists – apomorphine.
Melanocortin receptor agonists – melanotan.
Serotonin receptor effectors – trazodone.
Others – L-arginine, L-dopa, limaprost,
naltrexone, etc Intracavernosal injections
Alprostadil (synthetic prostaglandin E1)
Papaverine (non-specific PDE inhibitor)
Phentolamine (alpha adrenergic antagonist)
Vasoactive intestinal polypeptide
Intraurethral suppositories – prostaglandin E2 or E1
Transdermal/topical pharmacotherapy – alprostadil, nitroglycerine
Medical device (Vacuum erection device) – is comprised of battery operated pump (or sometimes a
manual pump in association with a plastic cylinder working as a vacuum-suction device. It is placed
directly over the flaccid penis and operated, and after the penis is erected an elastic constriction
ring or band is positioned at the base of the penis. Thereafter, the suction pressure is released and
the device is removed. It should not be left in place for more than 30 minutes.
Surgery
Penile prosthesis surgery
Arterial revascularization surgery
Venous reconstruction
Combination therapy
Alternative therapies – gingko biloba, L-arginine, Korean red ginseng

PENILE PROSTHESES (12)

There are two broad categories of penile implants, namely semi rigid rods and inflatable devices.
Device selection depends on surgeon’s experience, patient preference and patient anatomy.
SEMIRIGID RODS
Semi rigid rods are paired, solid cylinders that fill each corpus cavernosum. They can be further subdivided into:
Malleable devices – They have a central core that allows a patient to position the penis upward
for sexual intercourse and downward at other times.
Positional devices – They incorporate a series of articulating polyethylene discs with a central
metal cable support, which allow better maintenance of upward and downward positions.

Figure 4: MALLEABLE DEVICEFigure 5: POSITIONAL DEVICE

INFLATABLE PROSTHESES
Inflatable prostheses are manufactured in such a way that they simulate erection by increasing in
length and width and become flaccid when not in use. Each corpus cavernosum is filled with a hollow
cylinder which can be inflated with saline during sexual activity to produce rigidity and can be deflated
later on. Inflatable prostheses can be subdivided further into:
The two-piece device – It consists of the two cylinders and a scrotal pump. Reservoirs in the
proximal portion of the cylinders are prefilled with saline and connected to the pump via silicone
tubing. Pressing a valve mechanism in the pump transfers the solution from the reservoirs into the
distal, inflatable portion of each cylinder. Bending the cylinders down for several seconds activates
a release valve that deflates the device by allowing the fluid to flow back to the reservoirs. Cylinders
are typically available in several widths and lengths in accordance with person to person variation.
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 The three-piecedevice – It consists of two hollow cylinders, a scrotal pump, and a saline-filled
reservoir. Silicone tubing connects the cylinders to the pump and the pump to the reservoir.
Repeatedly squeezing the pump transfers saline from the reservoir to the cylinders until
adequate rigidity is achieved, and pressing a valve mechanism in the pump causes the fluid to
flow back to the reservoir, resulting in deflation mimicking flaccidity.

Figure 6: INFLATABLE PROSTHESIS

Similar to the two-piece devices, three-piece devices are also typically available in several widths and
lengths and come with optional rear tip extensions. One-touch release models and other more recent
innovations in pump design facilitate deflation. A three-piece device acts and feels more like a natural
erection. It is more rigid when inflated and is more flaccid when deflated.
Contraindications for Penile Prosthetic Surgery:
Situational erectile dysfunction (ED)
ED resulting from relationship conflict
Potentially reversible ED
Inability to follow instructions
Hygiene issues and skin cleanliness
Noncompliance with concurrent medication (e.g., for hypertension or diabetes)
Spinal cord injury
Uncontrolled diabetes mellitus
References
Tom F, Lue. Physiology of Penile Erection and Pathophysiology of Erectile Dysfunction. Campbell-Walsh Urology
(ed11). Philadelphia:2016:612-642
Hsu GL, Brock G, Martinez-Pineiro L, et al. The three-dimensional structure of the human tunica albuginea: anatomical
and ultrastructural levels. Int J Impot Res. 1992;4:117–129.
Hoznek A, Rahmouni A, Abbou C, et al. The suspensory ligament of the penis: an anatomic and radiologic description.
Surg Radiol Anat. 1998;20:413–417.
Sattar AA, Salpigides G, Vanderhaeghen JJ, et al. Cavernous oxygen tension and smooth muscle fibers: relation and
function. J Urol. 1995;154:1736–1739.
Droupy S, Benoît G, Giuliano F, et al. Penile arteries in humans. Origin—distribution—variations. Surg Radiol Anat.
1997;19:161– 167.
de Groat WC, Booth AM. Neural control of penile erection. Maggi CA. The autonomic nervous system. Harwood: London;
1993:465–513.
Andersson KE, Wagner G. Physiology of penile erection. Physiol Rev. 1995;75:191–236.
Lizza EF, Rosen RC. Definition and classification of erectile dysfunction: report of the Nomenclature Committee
of the International Society of Impotence Research. Int J Impot Res. 1999;11:141–143
Ralph D, McNicholas T. UK management guidelines for erectile dysfunction. BMJ. 2000;321:499–503.
Arthur L. Burnett II. Evaluation and Management of Erectile Dysfunction. Campbell-Walsh Urology (ed11).
Philadelphia:2016:643-66
Rosen RC. Evaluation of the patient with erectile dysfunction: history, questionnaires, and physical examination.
Endocrine. 2004;23:107–111.
J. Francois Eid. Surgery for Erectile Dysfunction. Campbell-Walsh Urology (ed11). Philadelphia:2016:709-722

PCNL (Percutaneous nephrolithotomy)

-Dr. Pawan Lal, Dr. Sumit Agrawal

Fernstrom and Johansson (1976) first reported the technique of creating a percutaneous tract
specifically to remove a stone.Percutaneous approach to stone removal is superior to the open
approach in terms of morbidity, convalescence, and cost, PNL has replaced open surgical removal of
large or complex calculi at most institutions (Matlaga and Assimos, 2002).Percutaneous
nephrolithotomy (PCNL) is the preferred treatment for large (>2 cm) renal or staghorn renal stones.
Indications :
Large stone burden ≥ 2 cm for lower calyceal stones.
Staghorn stones.
Stones those are difficult to disintegrate by ESWL (calcium-oxalate monohydrate, brushite, cystine).

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 Stones refractory to ESWL or ureteroscopy.
Urinary tract obstructions that need simultaneous correction (e.g. PUJ obstruction).
Malformations with reduced probability of fragment passage after ESWL (e.g. horseshoe or dystopic
kidneys, calyceal diverticula.)
Obesity

Absolute contraindication to PCNL

uncorrected coagulopathy
Active, untreated urinary tract infection (UTI).
If it is medically feasible, aspirin and other anti-platelet medications should be discontinued 7
days before the date of surgery.

Patient Preparation
Complete history and physical examination
Complete blood cell count, Serum Electrolyte, Renal function tests
Urine culture is mandatory for all patients who undergo PNL; peri-operative antibiotics can be
appropriately tailored to culturespecific organisms.
Helical computed tomography (CT) to evaluate the patient with urolithiasis has eliminated the
need to perform preoperative intravenous urography or retrograde pyelography.

The main advantage of CT is the ability to assess:-

The spatial relationship of the kidney relative to the stone and that of
The kidney in relation to adjacent peritoneal and retroperitoneal structures.
Patients with ectopic kidneys, both congenital and iatrogenic (e.g., due to renal allograft,
autotransplantation), as well as patients with dysmorphic body habitus because of congenital
malformations such as spinal dysraphism also may benefit from cross-sectional imaging
before PNL; intra-abdominal structures, such as the bowel, may be located between the skin
and the renal access point in such cases.

X-ray- KUB may be obtained immediately before the procedure to verify stone location if there is
concern for stone migration.Radionuclide scanning may be necessary in selected patients,
particularly those harboring staghorn calculi, to evaluate differential renal function.

Antibiotic prophylaxis:
The antimicrobial of choice is a first- or second-generation cephalosporin or an aminoglycoside with
metronidazole or clindamycin; ampicillin/sulbactam or a fluoroquinolone is recommended as an alternative.

Anaesthesia
PCNL can be performed after the administration of general, epidural, or local anesthesia.
In cases in which upper pole puncture is contemplated, general anesthesia is preferred because it
permits control of respiratory movements, which is essential to minimize the risk for pulmonary
complications. A close relationship between the surgeon and the anesthesia team is essential to
optimize the outcome of a PNL procedure

Steps of PCNL:
Cystoscopy and cystoscopy guided ureteric catheterization
Radiographic and skin template map of renal stones
Placement of access needle in collecting system
Dilatation of tract and placement of safety wire
Increase size of dilator and placement of access sheath
Locate and remove the stone
Flexible endoscopy of Renal stone
Nephrostomy tube placement

Percutaneous renal access can be considered the most important point in PCNL. Also ensuring the
correct depth of initial percutaneous needle insertion is considered one of the major impediments. It is
crucial to puncture through the centre of the calyceal papilla to avoid damage to interlobar and arcuate
branches of the renal artery that may occur with puncture directly into the infundibulum or renal pelvis.
Imaging techniques to assess the intrarenal collecting system, includes fluoroscopy, USG, and
CT. C-arm fluoroscopy is the most commonly used method. Radiation exposure is an
important point if the calyceal access is performed under fluoroscopic guidance. Renal
puncture under fluoroscopy carries a radiation exposure risk for the surgical team and the
patient. Total radiation dose of 50 mSv is the proposed annual dose limit for occupational
exposure by The International Commission on Radiological Protection.

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 The biological effects of radiation include infertility, cataract, skin damage, and hematopoietic,
gastrointestinal tract, and genetic changes, such as cancer.
In recent times USG-guided PCNL has been reported more frequently. The advantages of USG
guidance included the absence of radiation exposure, the ability to evaluate the residual non-
opaque and semi-opaque stones that could not be visualized by fluoroscopy, imaging of the
intervening structures between the skin and kidney (retro renal colon), the ability to distinguish
between anterior and posterior calyces.
The dilation of renal tract is important steps in PCNL. Three different basic techniques, including
Amplatz dilation (AD), metal telescopic dilation (MTD), and balloon dilation (BD) methods.
Balloon Dilatation has been generally regarded as the most modern and safe technique. Handa
et al.showed the superiority of a BD over AD via reducing the incidence of haemorrhage, blood
transfusion, and morbidity, as well as providing a shorter surgery time and recovery period.
Amplatz dilatation still remains as the best and first method by many urologists for tract dilatation.
Metal telescopic dilation is usually selected for usage when the other methods of dilation have been
failed or in the patients with severe perinephric scar tissue detected during diagnostic evaluation.
In comparing these methods, Balloon Dilatation is found to decrease the tract dilatation fluoroscopy time for both
patient and urologist, so it has been regarded as the most safe and effective method for renal tract dilation.
The last step before completion of PCNL, placement of a nephrostomy tube is considered as standard
procedure. Besides providing hemostasis, nephrostomy tube also prevents urinary extravasation
and maintains adequate drainage of the kidney, even if it causes discomfort, pain, and prolonged
hospitalization for the patients. The new modifications, such as retrograde applied ureteral catheter
or double J stent, used to alternatively drain the renal unit, known as tubeless PCNL.
Stone Removal:
After the nephrostomy access has been appropriately dilated and the Amplatz sheath positioned, the
urologist can proceed with stone removal by endoscopic techniques. Physiologic solutions should be used
for irrigation during PNL to minimize the risk for dilutional hyponatremia in the event of large-volume
extravasation (Carson, 1986). The height of the irrigant during rigid nephroscopy should be maintained at 80
cm or less above the patient to minimize intra-pelvic pressure and to prevent fluid absorption through
pyelovenous backflow(Miller and Whitfield, 1985). The use of an Amplatz working sheath also prevents
elevated intra-pelvic pressures. Rigid nephroscopy is performed initially, and stones up to 1 cm in diameter
can be grasped with rigid graspers or stone baskets and extracted intact through the 30-Fr Amplatz
sheath.Stones larger than 1 cm requirefragmentation before extraction.
Rigid nephroscopy is the preferred method for stone removal; however, only the simplest intrarenal
collecting systems can be completely inspected with a rigid nephroscope through a single access.
Therefore flexible nephroscopy should be used during every PNL to survey the entire intrarenal collecting
system for residual stone fragments. With an Amplatz sheath in place, pressurization of irrigation fluid (up
to 300 mm Hg) during flexible nephroscopy is used to adequately distend the collecting system and improve
visualization. The entire collecting system should be examined systematically, including the proximal
ureter. Injection of contrast material through the flexible nephroscope and occasional fluoroscopy is helpful
in maintaining orientation and verifying that each calyx has been inspected. Small stone fragments can be
removed with a stone basket passed through the flexible instrument, and larger stones can be fragmented
with laser. Alternatively, fragments may be flushed or manipulated into the renal pelvis, where they may be
retrieved more easily with rigid instruments.
The goal of PCNL is complete or nearly complete clearance of stone material at the time of the primary
procedure, which greatly simplifies secondary procedures, if necessary. Furosemide can be
administered intravenously when the nephrostomy tube is placed at the conclusion of PNL to promote
and to maintain diuresis. Multiple different sizes and shapes of nephrostomy tubes are currently
available for use at time of PNL. The role of nephrostomy tube drainage is to aid in healing of the
nephrostomy tract, promote hemostasis, prevent urinary extravasation, drain infection, and allow re-
entry if necessary. Recently, tubeless (ureteral stent is left instead of nephrostomy tube) and even
totally tubeless (no drainage device used) PNL have been introduced and popularized.

Technique Modifications.
In an attempt to decrease morbidity association with PNL, modifications have been made to the size
ofthe renal access tract, resulting in the new designations of
mini percutaneous nephrolithotomy
ultra-mini-percutaneous nephrolithotomy
micro-percutaneous nephrolithotomy

The mini-PNL was first introduced by Jackman and colleagues in 1997 and decreased using a 13-Fr
percutaneous access sheath for stone removal. It is associated with longer operative times and
technical limitations on the part of the operating surgeon because of the need to fragment stones into
small pieces and poor visualization in the presence of bleeding (Li et al, 2010); however, overall blood
loss and transfusion rates with mini-PNL are lower compared to those with standard PNL.

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Further miniaturization of the access to 11-Fr inner diameter/13-Fr outer diameter ureteral access
sheath has led to the ultramini-PNL, where stones are fragmented with a holmium laser and then
allowed to pass spontaneously down the ureter. Desai and colleagues (2013) reported a stone-free
rate of 97.2% at 1 month postoperatively, with a 16.7% overall complication rate.

Percutaneous lithotripsy has been described using a 4.85-Fr all-seeing needle, termed the micro-PNL.
The all seeing needle allows for visualization inside the kidney and directed laser lithotripsy using a
200-micrometer laser fiber (Desai et al, 2011).
A recent comparison of micro-percutaneous lithotripsy to ureteroscopy found similar stone clearance rates
between the two procedures, but a higher rate of postoperative pain and greater decrease in hemoglobin in
the micro-PNL patients (Sabnis et al, 2013). Although all of the recent technique modifications work to
decrease overall patient morbidity, because of technical limitations with the mini-, ultramini-, and micro-PNL
their exact role in the treatment of upper tract nephrolithiasis is uncertain and continues to be defined.

Complications of PCNL
Bleeding requiring transfusion
Hemorrhage requiring intervention
Fever
Sepsis
Colonic injury
Pleural injury
Extravasation /urine leak

TURP (TRANSURETHRAL RESECTION OF THE PROSTATE)

-Dr. Rajeev Sood

Prostatic Hypertrophy affects as much as 30% of the males above the age of 70 years ix. Medical
management is safe and effective in patients with mild to moderate enlargement of the prostate xgland. With
the newer minimally invasive means to resect the prostate, there are safer but equally effective options
available1. TURP still stands as the gold standard modality of treatment in spite of these newer advances.
Transurethral resection of the prostate involves the resection of chips of the prostatic tissue using a
resectoscope. Both monopolar as well as bipolar modes are available for resection.

Indications
Transurethral resection of the prostate is indicated in patients with:
Recurrent Haematuria
Recurrent Urinary tract infections caused by obstruction
Obstructive uropathy
Severe Lower Urinary tract symptoms not responding to medical management
Acute retention of urine not resolved after trial of catheter removal

Presence of large diverticulae, vesical calculi and high post void residual urine (Chronic retention) are
relative indications of surgical management.

Contraindications
Blood dyscrasias and presence of prostatic malignancy are absolute contraindications
to TURP. Large gland size and anticipation of a long resection time are relative
contraindications. Technique
Various techniques are described for the removal of the prostate per urethra, The commonly used
techniques include:
Barnes Technique:
Middle lobe is removed from 5 to 7 ‘o'clock from the bladder neck to the verumontanum. Resection of
the right lobe is initiated from the 7 to 11’ o'clock followed by the left lobe from 5 to 1 ‘o'clock. Unless
the anterior lobe is large, a strip of tissue is left intact.
Nesbit Technique is the most commonly used technique. In this technique the resection is initiated at
12’o'clock and the prostate removed in quadrants after creating a ventral plateau. The resection is
done as a series of horizontal cuts once the lateral lobe falls down.

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Alcocks and Flocks Technique
Prostate is divided into four quadrants and resection of each quadrant is carried out separately
independent of the other quadrants.

Position:
Lithotomy position is the standard position for TURP. The popliteal fossa need to be well padded.
Compression stockings or DVT pumps are recommended.

Energy Source: Electric current is the standard energy source for conventional TURP. Monopolar
cautery can be used with non ionic irrigation media such as Glycine, Sorbitol, Sterile water and urea
solutions. In monopolar cautery the current travels from the resection loop to the patient end plate
through the patient body including the prostate tissue.
Bipolar current can also be used in presence of ionic media such as normal saline. Specially designed
loops and generators are required for resection under saline. Here the current can travel through any
of the following paths:
One end of the loop to the other while creating plasma
Loop to the resectoscope sheath
Forward segment of the loop to the backward component of the loop (Using two parallel loops)
The advantage of the bipolar system is the elimination of the risk of TUR syndrome due to presence of
saline as the irrigation media, more clarity, self cleaning of the loop (due to generated plasma) and
lower risk of capsular lesion (due to reduced stimulation of pelvic musculature).

Irrigation Media:
The following irrigation fluids can be used to perform transurethral resection of the
prostate Sterile Water
Glycine 1.2%, 1.5%. 2.2%
Mannitol 3%
Glucose 2.5% - 4%:
Cytal: mixture of sorbitol 2.7% and mannitol 0.54%
Urea 1%
Normal Saline 0.9%

Complications
The complications of TURP are not uncommon and occur in about 20% of the cases2
TUR Syndrome: 0.5 to 8%
Bladder neck contracture: 0.3-9%
Urethral Stricture: Usually bulbomembranous or proximal bulbar stricture
Meatal Stenosis
Capsular perforation
Hemorrhage: Can be primary or secondary

TUR Syndrome:
When under regional anesthesia, the patient characteristically complains of

Dizziness
Headache
Nausea
Tight feeling in the chest and throat
Shortness of breath
Restlessness
Confusion
Retching
Abdominal pain
TUR Syndrome is a result of dilutional hyponatremia, Ammonium toxicity or
glycine toxicity. Novel Invasive Options
Photoselective Vaporization of the prostate involves vaporization of prostatic tissue with KTP laser. Potassium
titanyl phosphate laser has substantially more collimated beam with a potential to induce efficient
tissue vaporizationxixii.
Laser enucleation of the prostate: Holmium and Thulium laser can be used to enucleate the prostate.
Two lobe technique or three lobe technique can be used for the enucleation. Enucleated lobes are
subsequently morcellated and extracted.

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Prostatic Urethral lift is a new and minimally invasive technique for the management of LUTS
secondary to prostatic enlargement. Improvement of LUTS was better after TURP, whereas PUL turned
out to be superior in terms of quality of recovery, ejaculatory function, and quality of sleep. PUL can
be considered in selected patients with bothersome LUTS, with special interest in the complete
preservation of sexual function and a rapid and smooth return to daily activity.

REFERENCES:
1. Chute CG, Panser LA, Girman CJ, O esterling JE, Guess HA, Jacobsen SJ, et al The prevalence of prostatism: a
population based survey of urinary symptoms. J Urol 1993;150(1):85-9.

Woo MJ, Ha YS, Lee JN, Kim BS, Kim HT, Kim TH, YooES.Comparison of Surgical Outcomes Between Holmium Laser
Enucleation and Transurethral Resection of the Prostate in Patients With Detrusor Underactivity.IntNeurourol J. 2017
Mar 24;21(1):46-52. doi: 10.5213/inj.1732640.320.
Magistro G1, Stief CG1, Gratzke C2.Prostatic Urethral Lift Versus Transurethral Resection of the Prostate (TURP).
CurrUrol Rep. 2017 Aug 29;18(10):82. doi: 10.1007/s11934-017-0725-4.
1Oesterling JE. Benign prostatic hyperplasia. Medical and minimally invasive treatment options.NEngl J Med. 1995 Jan
12; 332(2):99-109.
1Magistro G1, Stief CG1, Gratzke C2.Prostatic Urethral Lift Versus Transurethral Resection of the Prostate (TURP).
CurrUrol Rep. 2017 Aug 29;18(10):82. doi: 10.1007/s11934-017-0725-4.

URODYNAMICS
-Dr. Santosh Aggarwal

Urodynamics (uro + dynamics) is the term used to define testing and measurement of differernt
functions of lower urinary tract. Lower urinary tract has two functions. Primary function is storage of
urine at low bladder pressure so that upper urinary tracts are protected and second is complete
evacuation of urine at appropraite time. When these functions are afftected by disease processes
either involving the lower urinary tract or neurologic diseases, Lower urinary tract symptoms (LUTS)
such as frequency, urgency, urge incotinece, poor flow of urine, hesitancy, intermittency, nocturia,
urinary incontinence etc. appear. Proper understanding of storage and emptying is necessary to treat
these symptoms. Urodynamics provides objective / quantitative assessment of storage and emptying
of urinary bladder and transport function of urethra; thereby guiding the line of treament.

COMPONENTS OF URODYNAMIC STUDY

Non-invasive tests (placing catheters not
required) - Uroflowmetry (UFM)
Post-void residual urine assessment
(PVR) Bladder diary
Invasive tests (placing catheters/needles required to measure
pressures/voltage) - Cystometrography (CMG)
Pressure-flow study (PFS)
Urethral pressure profilometry
(UPP) Electromyography (EMG)

Urolflowmetry (UFM) is measurement of urine flow rate overtime. It is an imporatnt component of

urodynamic study. It gives an idea of bladder emptying pattern. Multiple parameters can be reporterd
in uroflowmetry(Figure1). Eg;
Voided volume
Maximum flow
rate Average flow
rate Flow time
Time to maximum flow

In addition to this, pattern and shape of the curve gives important indication about bladder function. Normally, its
bell shaped curve (Figure1). A prolonged irregular pattern with poor flow (Figure 2) may indicate bladder neck or
prostatic obstruction. Interrupted or straining pattern may indicate detrusor under activity and flattened pattern
(Figure 2) may indicate fixed obstruction (e.g. Stricture of urethra). However, specific bladder or outlet abnormality
can not be fully judged unless we do multi-channel (invasive) urodynamic study.
Post void residual urine (PVR)is amount of the urine remaining in the bladder after voiding. It is
assesed by ultrasound measurement (preferable) or by cathetarization. Patients with bladder outlet
obstruction or hypocontractile derusor may have high PVR measurement.

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Figure 1. Normal uroflow graph Figure 2. Uroflow patterns
Cystometrographyis main component of urodynamic study where in pressure/volume relationship of the
bladder is measured during bladder filling. Double-lumen cathetar (called cystometry c atheter) is
inserted perurethrally for bladder-filling and ve sical pressure-measurement, and balloon-cathetar is
inserted in the rectum for intrabdominal pressure measurement. Bladder is filled slowly by cystometry
cath eter and change in intravesical pressure with bladder filling is plotted on computer screen.
Intravesical pressur e (Pves) represents combination of detusor pressure (Pdet) and abdominal pressure
(Pabd). Since, we are interested in the actual detrusor pressure (Pdet), it is derived from the following
equation in real-time by comp uter and plotted on screen -
Pdet = Pves – Pabd.
Interpretation – during CMG one can know about sensations of bladder (wheth er hyposensate or
hypersensate), abnormal activity of detrusor muscle (called detrusor overactivity) as well as
accommodation capacity of bladder measured by compli ance (∆Volume/∆pressure; low, normal, high)
Pressure flow study: During the cour se of study, once the bladder is full, the patient is asked to void
with cystometry and rectal catheters in situ, continuing the graphical display of pressures (Pve s, Pabd,
Pdet) and urine flow rate.
Interpretation– high pressures during voiding along with low flow rate indicate bladder outlet
obstruction. Low pressures during voiding along with low flow rates indicate detrusor underactivity.
Electromyography(EMG) is the meas urement of electronic potential of striated sphin cter muscle during
bladder filling and bladder emptying. It i s measured by electrode placed beside the anus (surface
electrode) or insrted in the sphincter muscle (needle electrode).
Interpretation– slowly progressive but regular EMG activity during filling phase indicates preserved
guarding reflexes. During voiding EMG activity is drastically reduced; a persistent or elevated EMG ac
tivity during voiding phase indicates detrusor external sphinctor dyssernergia (DESD) which is seen in
ce rtain patients with neurogenic bladder
URODYNAMIC EQUIPMENT AND SET UP
Urodynamic table and machine is set up in a room of appropriate size. There should be ade quate privacy
in the room so that patient remains relaxed d uring the study, an important measure to avoid m
isinterpretations of findings.
Set up consist of of following component (Figure 3):
Urodynamic apparatus consisting of a
Computer / laptop with standard peripherals and urodynamics software
Urodynamic hardware – consisting of automated filling pump, pressure transducers, EMG module
and uroflowmeter
Printer
Urodynamic table /couch
Consumables -
Cathetars (double-lumen cystometr y cathetar for bladder filling/ intravesical presuure measurement
and rectal balloon cathetar for intra abdominal pressure measurement)
EMG electrodes

Figure 3: Urodynamic equipment and setup

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 Urodynamic table /couch: Urodyna mic couch is specifically designed couch for urodyn amic study.
Patient lies on table and cathetars are put in supine or semi sitting positiion. It is motorized table and
patient can be made to sit during voiding. Patient void s in receptacle in sitting position.

Cathetars: Under aseptic precaution a double lumen 6F cathetar is put perurethrally which is used for bladder
filling and intravesicle press ure mesurement. For intra abdominal pressure m easurement, rectal balloon cathetar
is placed and filled w ith 5 ml of normal saline/water. In female patient abdominal pressure can be measured
through vagina as well. Rectal ballon cathetar gives indirec t measurement of intraabdominal pressure, any
pressur e rise in abdominal cavity is transmitted through re ctal ballon cathetar. The two cathetar are attached to
separate pressure transducer for intra abdominal pressure (Pabd) and intravesicle pressure (P ves). For bladder
filling 1 liter NS is attached to filling cathetar through the motorized pump. Bladder filling is started at slow fill rate
of 10 ml/min which is gradually increased if bladder is stable.

EMG electrodes are placed in perianal region (surface electrode) or inserted into anal / external urethral
sphicter (needle electrode). EMG elc trode is attached to EMG cable. Tracing of EMG activity is shown
at bottom of display on computer screen.

Urodynamic graph shows on computer display screen which has 5 or 6 tracing depending upon whether EMG
is being done are not. Top graph show s Pves (intravesicle presure), then below it Pdet (d etrussor pressure),
intraabdominal pressure (Pabd), Qura (flow rate) , bladder capacity and then EMG activity. ( Figure 4)

Figure 4 : A Representative Urodynamic graph

COMMON INDICATION OF URODYNAMICS

Young male patient with LUTS not responding to medical treatment.
BPH (Benign Prostatic Hyperplasia) patients with history of prolonged diabetes mellitus and suspected
diabetic cystopathy.
BPH patients with history of neurologic illness eg. parkinsonism, cerebro vascular accident etc
Female patients with confusing mix of stress and urge incontinence to guide appropriate th
erapy. Children with daytime urgency and urg e incontinence.
Children with persistent diurnal enuresis.
Children with spinal dysraphism.
Neurogenic bladder dysfunction to gui de appropriate therapy

PREREQUISITE FOR URODYNAMIC STUDY

Urodynamic question – Before starting urodynamic study in any patient, one should ha ve specific
question in mind which urologist want to know in that particular patient. Urodynamic question sh ould
be pertinent to patients LUTS and should help in managing voiding dysfunction in patient. History and
exaamination should be done in details before starting te study.
Urine culture should be sterile. If positive , then should be covered with appropriate antibiotics
Severe constipation should be treated so that at the time of examination rectum is empty.

PROCEDURE
After initial detailed assessment in out patient department, patient is given appointment for urodynamic
study. He / she is required to have passed stools before the test (laxative may be prescribe d night
before the procedure as needed). There is no need for fasting for the test, in fact a light meal is encour
aged so that patient is more comfortable. Patient should co me with full bladder if possible for a non-
invasive uroflowmetry before starting the invasive urodynamic study. Single dose of antibiotic (oral or
parenteral) may be prescribed as per local protocol.
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Initially, free uroflowmetry is done and PVR is assessed by sonography. Patient lies down in the
urodynamic couch. Firstly, EMG electrodes are placed followed by rectal balloon catheter with adequate
lubrication and are secured in place (clipping of perineal hair may be required for proper fixation). Lastly,
penis / introitus is painted with povidone iodine solution, urethra lubricated with sterile xylocaine jelly (2%)
and cystometry cathetar is inserted urethrally. Cystometry catheter is connected to inflow tubing and
pressure transducer, rectal catheter to pressure transducer and EMG cable to EMG module. All the tubings
are flushed with sterile normal saline to remove any air from the system (any air bubble will dampen the
pressure transmission adversely affecting recordings). Pressure transmission is checked on the
urodynamic-software screen by asking the patient to cough. Zeroing is done by keeping the transducers at
the level of pubic symphysis and opening the pressue tubing to atmospheric pressure.
After checking all the settings, bladder filling is started at slow filling rate (typically @30ml/min) and change
in pressure in studied continuously on monitor. First sensation of bladder filling , normal senstaion and
strong desire to void is marked on the screen. Filling is stopped at very strong desire to void and patient is
asked to urinate with all the connections in situ most typically in sitting position. After voiding PVR is
assessed again by aspirating through the cystometry catheter, completing the pressure flow study.

Typical urodynamic study graph

Figure 4 show a Multichannel urodynamics study showing filling and voiding phases with pressure and
electromyography (EMG) readings. It shows flow rate, bladder filling, intravesicle pressure (Pves), intra-
abdominal pressure (Pabd), detrussor pressor (Pdet), and EMG tracing from top to bottom. In this case, the
patient experienced an involuntary detrusor contraction (IDC), which led to increased external sphincter
contraction and an increase in EMG activity (guarding reflex). However, shortly after that the patient is given
permission to void. First there is quieting of the EMG (sphincter relaxation) followed by an increase in Pdet
and volitional voiding with a normal appearing uroflow curve.
SUGGESTED READINGS
Manual of Urodynamics: Mayank Mohan Agarwal; Jaypee brothers medical publishers (P) Limited.
Campbell- Walsh Urology: Chapter 73, 11th Edition; Elsevier

ENDOUROLOGICAL MANAGEMENT OF STONES AND

STRICTURE (OIU AND URS)
-Dr.Mrinal Pahwa

OIU
INTRODUCTION
Urethral stricture is one of the oldest urologic diseases with treatment of this condition described as early
as 600 years BC. It appears that the incidence of urethral stricture varies widely throughout the globe. In
developed countries like USA the prevalence of urethral stricture has been reported to be approximately
0.9% based on epidemiologic data in a Medicare population. In non-industrialized countries the incidence of
urethral stricture is thought to be even higher. The minimal invasive interventions most often used for
treating strictures are dilatation and Optical Internal Urethrotomy (OIU). Data show that there is no
difference between urethral dilation and internal urethrotomy in terms of long-term outcomes; success rates
range widely from 8–80%, with long-term success rates of 20–30%. Long-term success rates are higher for
surgical reconstruction with urethroplasty, with most studies showing success rates of 85–90%. This
chapter reviews the indications, techniques, complications and results for OIU.

INDICATIONS
Successful treatment depends more on appropriate case selection than on the the technicalities of
any particular procedure. Koraitim has pointed out that OIU and urethroplasty should be regarded not
as competing modalities, but as different complementary techniques available for the cure of different
types of strictures, each with its own indications and limitations.
The ideal indications for OIU are single strictures shorter than 2cm, with uninfected urine, no extensive
spongiofibrosis and no previous dilatation or OIU. Patients who are poor candidates for initial or repeated
OIU include those with multiple, long (2-5cm), penile or posterior strictures, with infected urine, extensive
spongiofibrosis, or stricture recurrence less than 3 months after previous OIU.
ANESTHESIA
Although some authors have reported routinely using general or regional anesthesia for OIU, several
studies have reported performing urethrotomy under local anesthesia in an outpatient setting, with
sedation is some cases. OIU can be performed using 10ml of 2% lidocaine or mepivacaine instilled
into the urethra. After urethersoscopy a second dose of 10ml of 2% lidocaine can be administered and
10 minutes are allowed to elapse before performing OIU.

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ANTIBIOTICS
In patients with infected urine, bacteremia may occur in up to 70% during OIU. Antibiotic prophylaxis
has been shown to reduce the incidence of bacteriuria after OIU in men with sterile urine and
antibiotic treatment of postoperative urinary tract infection may reduce the stricture recurrence rate.
Various antibiotics have been recommended for prophylaxis but an aminoglycoside or 3 rd generation
cephalosporin is the preferred antibiotic. The duration of antibiotic treatment varies from a single
perioperative dose to continuous treatment until 24hour after catheter removal.

PROCEDURE
Although the first endoscopic urethrotomy was performed in 1893 by Oberlander, the modern technique of optical
internal urethrotomy using a small knife introduced via a cystoscope was initiated by Sachse in 1971. The
technique described by Sachse involved a single cold knife incision through all visible scar tissue at the 12
o’clock position. Modifications of this technique aimed at increasing its efficacy and safety include the following:
Multiple radial incisions
Resection of the scar tissue between the 1 and 11 o’clock positions
Substituting the cold knife for a hook electrode
Laser urethrotomy using different types of lasers
Targeted incision of fibrosis as demonstrated by ultrasound
Bipolar plasmakinetic vaporization
The technique of OIU is relatively simple. The urethrotome with a 0 or 12 otelescope and a 19 or 21 F sheath is
inserted through external meatus and advanced under vision up to the stricture. It is, of course, important to keep
the blade withdrawn. The irrigant fluid should be isotonic (normal saline is ideal, unless electrodiathermy is to be
used) because if there is extravasation it minimizes tissue damage and avoids the risk of hyponatremia.
Via the side channel of the urethrotome, a 5F ureteric catheter or guide wire is inserted through the stricture,
preferably all the way into the bladder. If the stricture is very short and the operator is experienced, the stricture
may be incised without a guide wire, but there is a real risk of cutting a false passage. As the stricture is opened
up, the urethrotome is advanced, and further incisions are made until the full thickness of the stricture has been
divided up to the normal proximal urethra. A foley catheter is usually placed after OIU. If there is difficulty in
placing a Foleys catheter after the procedure, a ureteric catheter or firm guide wire can be left indwelling at the
end of the procedure and Foleys catheter threaded over the ureteric catheter or guide wire after cutting off the tip
of Foleys catheter. Alternatively a urethrotome with half round sheath can be used to place the catheter.
CATHETERISATION
The size of foley catheter inserted after OIU varies from 14 to 20 F but there is no convincing evidence
that catheter size has a significant effect on stricture recurrence rate. The reported duration of
catheterization has varied from 1 day to 3months. However, most studies have reported
catheterization for 1-4 days. Longer periods have been used for more complicated procedures.

COMPLICATIONS
The relative safety of OIU has been well documented with morbidity rates as low as 8-9%. Minor complications
usually occur in less than 10% of cases. A review of literature showed that the most commonly reported
complications of OIU are urethral hemorrhage and perineal hematoma (each 20%). Other complications rates
reported in various studies include scrotal edema 13%; creation of false passage 10%; rectal perforation 10%;
epididymorchitis, meatal stenosis, and incontinence (each 9%); fever 3.6%; extravasation 3.4%; bacteremia 2.7%;
urinary sepsis 2.1%; and scrotal abscess 1.4%. Erectile dysfunction is reported by some authors as a complication
of OIU in 2-11% of cases. Other rare complications include high flow priapism or a urethral internal pudendal
artery fistula or life threatening septicemia. A late complication of repeated OIU may be that it increases the degree
of spongiofibrosis and thus compromises the success rate of subsequent urethroplasty.

RESULTS
In the early 1980s, the reported “immense success” of the Sachse urethrotomy was reflected in a
dramatic decrease in the number of urethroplasties being performed worldwide. The 2 year cure rate
was stated to be more than 80% and it became the initial treatment of choice for most strictures of
male urethra. However, it soon became clear that the length of follow-up was the most important
determinant of recurrence. Various studies reported success rate of 56% at 6 months, 43% at 1 year,
and 255 at 2 years: 95% at 6 months and 55% at 38 months: 55% at 6 months and 35% at 2 years.
Some studies noted stricture recurrence long after OIU with 5 year success rate of 25-36%.

RIRS/URS
Urolithiasis is common with a lifetime prevalence estimated at 1% to 15% .26The treatment options for stone
removal vary from conservative options to minimally invasive options like extra corporeal shortwave lithotripsy,
percutaneous lithotripsy, ureteroscopy and open surgeries. Ureteroscopy is defined as upper urinary tract
endoscopy performed most commonly with an endoscope passed through the urethra, bladder, and then directly
into the upper urinary tract. In 1978, a paediatric cystoscope was used to examine a dilated distal ureter in a
female. The technique has improved dramatically over the past 2 decades, and has evolved into a minimally
invasive procedure for the diagnosis and treatment of pathology within the upper urinary tract.
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Today, the vast majority of intrarenal calculi are accessible and treatable using a retrograde
ureterorenoscopic approach. The development of smaller caliber, longer, and more nimble
ureteroscopes has driven this revolutionary advance. This progress has resulted in a revolution in the
management of urolithiasis and an ever-increasing role in oncology treatment.

INDICATIONS
Diagnostic indications for ureterorenoscopy are as follows:
Abnormal imaging findings - Filling
defect Obstruction - Determination of
etiology Unilateral essential hematuria
Localizing source of positive urinary cytology results, culture results, or other
test results Evaluation of ureteral injury

Endoscopic lithotripsy
Retrograde endopyelotomy
Incision of ureteral strictures
Improvement of calyceal drainage
Treatment of calyceal diverticular lesions
Treatment of malignant urothelial tumors
Treatment of benign tumors and bleeding
lesions Contraindications
Untreated urinary tract infection, endoscopy without appropriate antibiotic coverage, and
uncorrected bleeding diathesis are relative contraindications.
Relative contraindications also include anatomical situations aggravating retrograde access such as
phimosis, urethral stricture, large prostate adenomas, ureterocele, ureteral strictures and also
coxarthrosis or former urological surgery such as ureteral re-implantation or urinary diversion.

Plain abdominal radiography (kidney, ureter,bladder, KUB) and intravenous pyelography (IVP).
Radio contrast imaging gives important information on renal spatial anatomy, which is mandatory
for optimal preoperative planning of flexible ureterorenoscopies. Estimation of the infundibulopelvic
angle can give information, if the lower renal poleis accessible with the available flexible scope.
Retrograde pyelography is useful if intravenous contrast agent cannot be injected.
Abdominal helical CT scan has displaced routine KUB/IVP in many centres because it offers
fast diagnosis without using contrast agents. However, X-ray exposure and costs are higher
than for KUB/IVP.
Ultrasound.

Stop anticoagulants (acetyl salicylic acid, cumarines/warfarin, clopidogrel) 7–10 days before.
Any urinary tract infection (UTI) should betreated by antibiotics according to sensitivity.
Perioperative antibiotics (a first-generation cephalosporin or fluoroquinolone is administered).
Thrombosis prophylaxis with low-molecular-weight heparin starting the evening before
operation. Patient Positioning
Patients are placed in lithotomy position.
Abduction and lowering of the contralateral leg improves freedom of movement for the
endourologist. Equipment
URS should be performed ideally with real-time fluoroscopy and video endoscopy. Fluoroscopy
during the procedure allows visualization of the ureter with contrast media and adds valuable
information for a successful ureteroscopy.
Anesthesia
General anesthesia or spinal anesthesia. Spinal anesthesia has been demonstrated to be safe
and feasible for distal ureter stones, while general anesthesia should be preferred for proximal
ureter and kidney stones.
Intravenous analgesia has been shown to be sufficient for distal ureter stones in female patients

URETERORENOSCOPES
Semi-rigid URS
The first ureteroscopy was performed in 1912 by Hugh Hampton Young in a patient with posterior urethral
valves when a rigid cystoscope was advanced into the dilated ureter ( Young and McKay, 1929
)
Modern ureteroscopes with calibers of 6–10.5 Fr do not require dilation of the intramural ureter.
Larger instruments should no longer be used.
Most scopes consist of optical channel, light fibers and one combined working and irrigation channel.
Scopes with separate irrigation channels allow continuous irrigation flow and therefore optimized
endoscopic view. The caliber, however, is larger than of scopes with one combined channel.
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Flexible URS
Flexible scopes with calibers of 6.5–9 Fr can be introduced into the upper urinary tract without
prior ureter dilation.
While flexible scopes are used proximal from the iliac vessel crossing by many urologists in
the United States, we recommend the use of semi rigid scopes inside the ureter whenever
possible. However, for the passage of difficult anatomy such as strictures, kinking or ureter
wall edema, a flexible scope may be necessary.
Most flexible scopes have an active, bilateral deflection mechanism at the tip and a passive
deflection mechanism proximally of the tip. Recently, a scope with two separate active
deflection mechanisms has been introduced.
While most standard flexible scopes have maximal deflection angles of 120°–180°, a new
generation of flexible ureterorenoscopes have bilateral deflections >270°.
A second advantage of such new-generation endoscopes is a stiffer shaft that improves
durability and controllability.
Manufacturers have reduced the caliber of the latest generation of fURS. The size of the scopes depends
on the model and its characteristics (e.g., fibreoptics digital scopes), while most of the fURSs are
equipped with a standard 3.6 Fr working channel and a 270 odeflection system in both directions.
Digital scopes have been introduced to improve the outcomes by providing better visibility,
maneuverability, and durability.

STONE DISINTEGRATION
INTRACORPORAL LITHOTRIPSY
Intracorporeal lithotripsy will be necessary for most fragments with sizes exceeding 3–4 mm. Several
different systems are available.

Electrohydraulic
Principle: electric current generates a flash at the tip of the probe; the resulting heat produces
cavitation bubble leading to aspheric shockwave.
EHL is able to disintegrate stones of all chemical compositions.
The undirected transmission of heat comes with a frequent risk of tissue injury, which is why
EHL is no longer use as a standard procedure.
Flexible electro hydraulic probes (EHL) are available in different sizes for use in semi rigid or
flexible scopes.

Pneumatic or ballistic lithotripsy probes with 2.4-F probes are frequently used in semi rigid
URS with disintegration rates over 90%.
Safe usage and excellent cost effectiveness are advantages of these systems.
The resulting mobilization of fragments into more proximal parts of the urinary tract may
decrease the stone-free rate. The insertion of stone baskets or special collecting tools such as
the ‘stone cone’ can prevent this loss of fragments.
Flexible probes are available but potentially impair the maximal tip deflection of the scope.

Principle: ultrasound-based lithotripsy probes induce high-frequency oscillation which

produces ultrasound waves (23,000–27,000 Hz).The ultrasound is transmitted to the tip of
theprobe, leading to a vibration that disintegrates the calculi after contact.
Combined ultrasound/pneumatic probes are available and can be used for semi rigid URS and PNL.
Laser-Based Treatment
The neodymium: yttrium-aluminum-garnet (Nd: YAG) and the holmium: YAG (Ho: YAG) laser are
mostly used for Intracorporeal laser lithotripsy.
Several fibers are available for both lasers, 365-μm fibers are typically used in semirigid, 220-μm fibers
in flexible scopes.
Nd: YAG: frequency-doubled lasers (FREDDY, 532 and 1064 nm) are used for lithotripsy.
Efficiency is low for hard stones such as calcium oxalate-monohydrate.
Cystine stones cannot be disintegrated with the Nd: YAG laser.
Low costs of the Nd: YAG laser compared to the Ho:YAG laser make this laser an
interesting alternative.
Ho: YAG: this laser type (2100 nm) can disintegrate all chemical stone compositions.
Currently the method of choice for stone treatment by flexible URS.
In comparison to the Nd: YAG, low tissue penetration of less than 0.5 mm produces
fewer thermal injuries.
Less stone migration than with ballistic probes.
Laser probe must have contact to the stone surface.
Perforation of the ureter or pelvic wall is possible. An increased incidence of strictures
could not be demonstrated.
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STONE EXTRACTION
Stone Manipulation within the Ureter
Small fragments can be extracted directly or after prior disintegration with a forceps.
The forceps must be pushed until the whole opening mechanism is out of the working channel
to assure correct opening of the branches.
The advantage of a forceps is easy release of a fragment.
The use of baskets is also possible, but has a higher risk of ureter wall damage or even
sticking inside the ureter.
Baskets are able to extract several small fragments at the same time. The endoscopic view is
better than with a forceps because of the smaller caliber.
Baskets (single-use) are less cost-effective than forceps (multi-use).

Stone Manipulation inside the Kidney

Baskets made of nitinol (nickel-titanium alloy) are suitable for use with flexible URS because of
their flexibility and low risk of trauma during stone extraction. Especially the ‘tipless’ baskets
are extremely a traumatic and ideal for use inside the kidney.
The use of stone extraction and disintegration tools impairs maximal scope deflection
indifferent extent. Urologists must know these factors preoperatively.

Retrograde pyelography, guidewire.

Retrograde pyelography can be used to recognize potential anatomical difficulties.
Insertion of a safety wire (allows stenting even after ureter perforation).
Dilatation
Pre-Stenting
Modern thin ureteroscopes allow direct intubation of the ureteric orifice without prior dilation
in most cases.
If primary intubation is not possible with reliable forces, stenting and later URS after 7–14 days
offers a safe alternative to mechanical dilation.
If ureter dilation is necessary, several types such as balloons or plastic bougies are available. However,
pre-stenting for 7 days before a second attempt is less traumatic and should be
preferred. Scope Introduction

To avoid high intrarenal pressure, the irrigation fluid should be maintained within a height of
20–40 cm H2O abovethe patient.

Ureteric access
Semirigid scopes can be introduced along the safety wire. Theguidewire can be used to open
the orifice tent-like when the scope is passed laterally under the wire.
If the ureter orifice cannot be intubated:
– Use a second wire which is passed through the working channel.
– Empty the bladder to reduce compression on the intramural ureter.
– Rotate the instrument which is not round but oval.
Flexible scopes are inserted in most cases via a guidewire (which should have two
floppy tips to avoid damage of the vulnerable working channel). The latest-generation
flexible ureteroscopes have a stiffer shaft that allows direct orifice intubation for the
experienced surgeon.
After access to the ureter, the scope is passed slowly and carefully until the
stone is reached. Ideally, the whole ureter circumference should be visualized
during the entire procedure. Because of narrow ureter parts and peristalsis, this
will not be possible all the time. However, the instrument should never be pushed
forward when the tissue mucosa is not moving.siumltaneously.
If the view inside the ureter is not sufficient:
Use more irrigation
- Inject contrast media through the scope to visualize the ureter anatomy
- If the view is poor because of bleeding and cannot be improved by
irrigation, finalise the procedure and insert a DJ stent over the safety wire.

Access Sheaths
-Access sheaths of several calibers are available and can be
introduced into the ureter via a guide wire.
-Their use facilitates access to the proximal ureter and the kidney, especially
in cases with large stone mass requiring multiple ureter passages. However,
most procedures are possible without use of such devices

232
 A second advantageous aspect when using access sheaths is maintaining low pressure
inside the upper urinary tract and therefore reducing the risk of septicaemia.

Small fragments are directly extracted by forceps or

baskets. Disintegration
Resulting fragments after disintegration should be small but large enough for easy extraction.
When using a Ho: YAG laser, the result is sometimes more ‘dust’ than ‘fragments’. Such
small residuals have a high probability of spontaneous passage and can be left in the
urinary tract (‘smash and go’). However, patients should be followed up to ensure they
reach a stone-free state.

DJ-catheters themselves have considerable morbidity. Therefore, routine postoperative

stenting should not be performed.
Stenting after URS is necessary only in the following cases: significant residual
fragments, ureter wall injury or perforation, long OR-time, ureter wall edema (stone bed).
Duration of stenting depends on particular indication, 7–14 days are sufficient in most cases.
OPERATIVE TRICKS
If the patient is placed in the Trendelenburg position (head lowered), mobilization of stone
fragments into lower calices can be avoided because stone fragments will fallinto upper
calices, which are now the lowestpoint of the kidney.
Stones within the upper calices can be reached in some cases by semirigid URS,
facilitating stone manipulation.
If direct insertion of a flexible ureteroscopeis not possible, prior semirigid
ureteroscopy‘optically’ dilates orifice and ureter. This type of dilation is less traumatic
than mechanical dilation and allows later flexible URS in mostcases.
Lower caliceal stones are often easier to disintegrate after mobilization to the renal pelvis
or an upper calyx. Baskets or a nitinol grasper can be helpful for stone mobilization.
If a calyx is not accessible with flexible URS, emptying of the renal collecting system with a
syringe (use of a three-way switch on aworking/irrigation channel) may facilitate the procedure.
If a stone basket sticks inside the ureter, the handle of the basket can be removed to get the scope
out of the body (according to the user's guide of the basket manufacturer). Afterwards, the
ureteroscope can be inserted again beside the basket wire. If disintegration of the fragments caught
inside the basket does not relieve the basket, the wires can be cut carefully by a Ho:YAG laser.
However, a safety wire should have been placed before and complete removal of all residual basket
wires should be assured. A less risky but more time-consuming method is the
application of SWL on the basket.

Patients after URS do not require specialpostoperative care, which is why the procedureis
performed on an outpatient basis inmany countries.
If stents were placed, the surgeon is responsible for removal of the stent. A follow-update
should therefore be fixed when the patient is discharged.

Risk of significant complications after URS is approximately 10%.

Bleeding is the most common intraoperative complication and may require second-look
ureteroscopy when endoscopic view deteriorates.
Perforations of the ureter or renal pelvic wall may occur during stone disintegration or extraction,
depending on the type of disintegration and the surgeon’s experience. Such perforations are treated
by insertion of an indwelling stent for 14 days and do not require surgical treatment.
Ureteric avulsion remains the major complication of URS and is extremely rare (<0.5%). It
usually requires open surgery.

Haematuria occurs frequently for 1–2 days but almost never requires active intervention.
The incidence of urinary tract infections is between 5% and 15% and can be treated with
antibiotics.
Fever due to bacteremia is described in 3%–5% of all patients.
The most common cause of postoperative fever or pain is an obstructive, non-stented
ureter. Therefore, when drawing the decision between stenting or not, it should be kept in
mind that the morbidity of urinary obstruction is higher than that of stenting. We still
recommend stenting in any doubtful cases.
 If obstruction is the reason for postoperative fever, a DJ-stent has to be inserted as soon
as possible. If retrograde stenting is not possible, a percutaneous nephrostomy (PCN) has
to be undertaken.
Ureteric strictures are long-term complications of traumatic procedures, perforations or
inflammatory stone beds with an incidence less than 1%.

RESULTS
The guidelines pooled numerous studies to evaluate outcome success for URS for upper
ureteric stones and different sizes, demonstrating an overall success of 81% for proximal
and 86% for mid-ureteral stones. Calculi 1 cm or smaller again demonstrated higher
success rates in both groups than did larger stones.
In the same ureteral calculi guidelines analysis, URS for the distal ureteral calculus was
shown to yield a 94% overall success rate, with stones 1 cm or smaller at 97% and over 1
cm at 93% success rate.

Suggested reading:
Campbell Walsh Urology. 11th edition
Smith’s Textbook of Endourology
AUA guidelines on Urolithiasis
EUA guidelines on Urolithiasis

SURGICAL MESHES
-Dr. Deborshi Sharma, Dr. Saurabh Sekhar

Surgical mesh is loosely woven sheet which used as either a permanent or temporary support for
organs and tissues. Surgical mesh is created from both inorganic and biological materials and is
used in a variety of surgeries. Hernia repair surgery is the most common application,but it is also
used for reconstructive work, like in pelvic organ prolapse.1
Permanent meshes remain in the body, whereas temporary ones dissolve over time. For
example, TIGR Matrix test mesh fully dissolve after three years.2 Some types of mesh combine
permanent and temporary meshes such as Vipro, which includes both re-absorbable vipryl,
made from polyglycolic acid, and prolene, a non-reabsorbable polypropylene.3

MESH PROPERTIES
TENSILE STRENGTH
The tension placed on the abdominal wall can be calculated by the law of Laplace which states
that in an elastic spherical vessel (abdomen), the tension, pressure, wall thickness and diameter
are related by: Tension = (Diameter × Pressure)/(4 × Wall thickness)’.
The maximum intra-abdominal pressures generated in healthy adults occur whilst coughing and
jumping. These are estimated to be about 170 mmHg.4 Meshes used to repair large hernias, therefore
need to withstand at least 180 mmhg ( up to 32 N/cm). This is easily achieved as even the lightest
meshes will withstand twice this pressure without bursting (for example, burst pressure of Vypro
= 360 mmHg5).

PORE SIZE
Porosity is the main determinant of tissue reaction. Pores must be more than 75 μm to allow
infiltration of macrophages, fibroblasts, blood vessels and collagen. Mesh with larger pores have
increased soft tissue in-growth and are flexible due to avoidance of granuloma bridging.
Granulomas forms around mesh fibres as part of the foreign body reaction. Bridging means
granulomas become confluent with each other and encapsulate entire mesh. Leading to a stiff
scar plate and reduced flexibility occuring in meshes with small pores less than 800 μm.

WEIGHT
The weight of the mesh depends on both the weight of the polymer and the amount of material used (pore
size).6 Heavy-weight meshes use thick polymers; have small pore sizes and high tensile strength.

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These meshes typically weigh 100 g/m2 (1.5 g for 10 × 15 cm mesh). The strength is derived from
a large mass of material, which activates a profound tissue reaction and dense scarring.
Light-weight meshes are composed of thinner filaments and have larger pores (> 1 mm). Their
weight is typically 33 g/m2 (0.5 g for 10 × 15 cm mesh). They initiate a less pronounced foreign
body reaction and are more elastic. Despite a reduced tensile strength, they can withstand
pressures above maximum abdominal pressure of 170 mmHg (16 N/cm).
A new generation of even lighter meshes includes the titanium/propylene composite meshes.
These have been shown to be associated with a more rapid recovery in a recent, randomised
controlled trial (RCT).7 the lightest of these (Extralight TiMesh) may have insufficient tensile
strength in some situations (maximum tensile strength 12 N/cm).

REACTIVITY/BIOCOMPATIBILITY
Modern biomaterials are physically and chemically inert. They are generally stable, non-immunogenic
and non-toxic. Despite they are not biologically inert.5 A foreign body reaction is triggered by their
presence involving inflammation, fibrosis, calcification, thrombosis and formation of granulomas. It is
very different from the physiological wound healing of suture repair.7 The foreign body reaction is
fairly uniform regardless of the type of foreign material, but the extent of the reaction is affected by
the amount of material present. Thus pore size is once again the determining factor for meshes. As
described above, meshes with small pores develop stiff scar plates which are avoided in meshes with
larger pores where there is a gap between the granulomas.
Meshes also appear to alter collagen composition.In normal scar healing, initially, immature, type III
collagen is rapidly replaced by stronger, type I collagen. This is delayed in the presence of a foreign
body like mesh. Resulting much lower ratio of type I/III collagen, thus reduced mechanical stability.
This effect occurs regardless of the type of mesh used, although the amount of collagen laid
down is higher in microporous meshes.

ELASTICITY
The natural elasticity of abdominal wall at 32 N/cm is about 38%. Light-weight meshes have an
elasticity of about 20–35% elasticity at 16 N/cm.4 Heavy-weight meshes have only half this
elasticity (4–16% at 16 N/cm) and can restrict abdominal distension.

CONSTITUTION
Mesh fibres can be monofilament, multifilament (braided), and patches (like, ePTFE).
Multifilament fibres have a higher infection.
SHRINKAGE
Shrinkage occurs due to contraction of the scar tissue formed around the mesh. Scar tissue shrinks
to about 60% of the former surface area of the wound.5 The smaller pores of heavy-weight meshes
lead to more shrinkage due to the formation of a scar plate Prolene shrinks 75–94%, PTFE shrinks 40–
50%, Vypro II shrinks 29%, Ultrapro shrinks < 5%, and Sofradim shrinks < 5%.

IDEAL MESH
Should invoke favourable host response, be strong enough to prevent recurrence,place no
restrictions on post implantation function, perform well in presence of infection, resist shrinkage
or degradationover time, make no restriction on future acess, block transmission of infection,be
inexpensive,easy to manufacture, possess good handling characteristics.
Which mesh should surgeons use?
One should look for a light-weight mesh, with large pores and minimal surface area. Ideally, it should
consist of a monofilament. A polypropylene or polyester mesh is, therefore, usually suitable (for
example, Paritiene Light, Optilene, Mersilene). These meshes will be more comfortable and have a
lower risk of infection. For the peritoneal cavity, one should minimise adhesions by choosing a hybrid
mesh with an absorbable surface. In infected wounds, absorbable mesh is used, like, polyglactin
(Vicryl) or polyglycolic (Dexon). Biomaterials are also useful if the additional cost can be justified.
Finally, mesh should not be small or fixed under tension, there will be complications.

NORMAL PERITONEAL HEALING: MESOTHELIALIZATION

The parietal peritoneum have single layer of mesothelial cells covering a continuous basement
membrane. This overlies loose connective tissue consisting of fibroblasts, collagen fibers,
adipocytes, leukocytes, lymphatics and microvasculature. The visceral peritoneum's basement
membrane overlies the extracellular matrix of the specific organ. Healing and regeneration of
injured peritoneal mesothelium is unlike that of any other epithelial-like surface.

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Defects in the parietal peritoneum, in contrast, heal by simultaneous epithelialization of the entire
surface. Hence complete mesothelialization, developing from multiple points throughout the defect,
occurs just as rapidly for large and small defects.8 The peritoneum remesothelializes in 5–8 days and
if adhesions can be prevented during this critical period, perhaps biomaterial-related complications
can be prevented or reduced. This neoperitoneum serves not only as a physical barrier separating the
mesh from the abdominal viscera but potentially promotes fibrinolysis through the release of tissue
plasminogen activator and inhibition of cell-cell and cell-tissue interaction through the release of
hyaluronic acid.8 While the severity and extent of adhesions may change over weeks and months, the
incidence of adhesions - that is, whether they develop at all - is decided in the first 5–7 days after
peritoneal trauma takes place. Development of intraperitoneal adhesions begins at the time of incision
when surgically traumatized tissues in apposition have their first opportunity to bind with fibrin
bridges.9 The ideal product for the prevention of adhesions should therefore be easy to apply, remain
where placed for 7 days, produce no inflammation or foreign body reaction, not impair wound healing
or mesothelial cell growth and migration and absorb when no longer needed.8

Classification of surgical meshes:

Type 1: totally macroporus prosthesis with pore size >75 microns
Example- prolene, marlex
Type 2: totally microporus prosthesis with pore size <10 microns
Example – gortex, dual mesh
Type 3: macroporus prosthesis with microporus component
Example – Teflon, mersilene
Type 4: biomaterial with submicronic pore size
Example – cilastic, cell gard

Types of Meshes
Polypropylene mesh is most widely used for the past 20 years because of its stability,
strength, inertness and handling qualities. These meshes are made up of polypropylene fibers
arranged in a network with pores of differing sizes. The product differs regarding size of the
monofilament material, size of pores, its thickness, pliability and shrinkage. They are known as
Marlex (Davol Inc, Cranston, USA), PROLENE (Johnson and Johnson, India), PROLENE Soft
(Johnson and Johnson, India) and Surgipro - multifilament (Tyco Healthcare, USA).
Monofilament mesh is preferable as it is less likely to give rise to infection.
Polyester meshes (Dacron, MERSILENE [Johnson and Johnson, India]) are not very popular
with laparoscopic surgeons though they are widely used in France and were used for hernia
repairs by Stoppa technique.
PTFE meshes are smooth, soft and strong. They allow good tissue ingrowth. They are more
expensive.
The first two meshes are ideal for use where they do not come in contact with the abdominal
viscera, viz, laparoscopic repairs of inguinal hernias - TAPP or TEP. Though some use it as intra-
abdominal placement for ventral and incisional hernias, but not advisable due to complications
of bowel adhesions, bowel obstruction, fistulization and erosion into abdominal viscera even
after many years. Polypropylene mesh in the abdominal cavity can be a disaster for the surgeon
who has to do next operation on that patient. 10 Latest technological advances have now made
available prosthetic materials which prevent bowel adhesions.

Lightweight composite meshes without barrier

VYPRO II and ULTRAPRO (Johnson and Johnson, India) are meshes designed to reinforce weak
tissues in open repair of inguinal hernias, TAPP, or TEP. They consist thin filaments of VICRYL
and PROLENE (Johnson and Johnson, India) or MONOCRYL (Johnson and Johnson, India) and
PROLENE (Johnson and Johnson, India). These filaments are twisted together then knitted to
form a requisite mesh structure. They are partially absorbable since 50% VICRYL or MONOCRYL.
They are macroporous, the pore size being 4.5 mm and this induces a better tissue ingrowth for
strong three-dimensional collagen fiber network.10 Almost with 70% reduction of implanted
foreign body and results in ‘scar-mesh’ as opposed to ‘scar-plate’. These provide enough
strength to the tissues with optimum mobility to the abdominal wall. Intraperitoneal placement of
the mesh requires a material which has both high tissue ingrowth towards the abdominal wall
and nonadhesiveness on the other side to prevent bowel adhesions.For this composite meshes
with absorbable and nonabsorbable barriers were engineered.11

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In composite meshes, the layer facing the abdominal cavity prevents adhesions with the bowel
while the layer in contact with the abdominal wall encourages high tissue in growth in polyester,
polypropylene or ePTFE.

Absorbable barrier composite meshes

Sepramesh:
Sepramesh Biosurgical composite (Genzyme Biosurgery, Cambridge, USA) is a dual-component
prosthetic biomaterial composed of macroporous polypropylene on one side, with bioresorbable,
nonimmunogenic membrane of sodium hyaluronate and carboxymethyl cellulose on the other side.
Seprafilm provides protection against intra-abdominal adhesion formation throughout the critical
period of remesothelialization during first postoperative week. The absorbable barrier turns to a gel in
48 h, remains on the mesh for ∼7 days and is cleared from the body in 28 days. This antiadhesive
material forms a physical barrier on damaged surfaces to prevent adherence. The physical barrier
should allow injured tissues to heal separately from each other. the sodium hyaluronate and
carboxymethyl cellulose are anionic polyaccharides forming a membrane that is negatively charged, a
molecular property that promoting separation of healing tissues.

Parietex Composite and Parientene Composite meshes:

Parietex composite (Sofradim, France) is composed of multifilament polyester mesh with a purified,
oxidized bovine atelocollagen type I coating covered by an absorbable, antiadhesion film of polyethylene
glycol and glycerol. Polyethylene glycol is a hydrogel that decreases tissue adherence and glycerol is a
hydrophobic lipid. The collagen coating functions to promote collagen ingrowth by increasing the
hydrophilicity of the polyester mesh and decreasing the fibrous tissue reaction to the ‘foreign’ material
(mesh). The collagen, polyethylene glycol and glycerol film are resorbed in ∼3 weeks. Parientene composite
mesh consists of the same antiadhesive barrier but coated to polypropylene.

PROCEED surgical mesh:

PROCEED surgical mesh (Johnson and Johnson, India) is a sterile multilayered, thin, flexible,
laminate mesh comprised of an oxidized regenerated cellulose (ORC) fabric; and PROLENE soft
mesh, a nonabsorbable polypropylene mesh which is encapsulated by a polydioxanne polymer.
The polypropylene mesh side of the product allows for tissue ingrowth, while the ORC side
provides a bioresorbable layer that physically separates the polypropylene mesh from
underlying tissue and organ surfaces during the wound-healing period to minimize tissue
attachment to the mesh. The polydioxanone provides a bond to the ORC layerIt has a lightweight
macroporous mesh construction, leaves behind less residual foreign body, allows the fluid to
flow through easily and does not harbor bacteria..

Nonabsorbable barrier composite meshes

Bard composix mesh (Davol Inc, Cranston, USA):
This is a combination of polypropylene that has a thin coat of ePTFE on one side to prevent
bowel adhesions. Introduction through a laparoscopic port is difficult because it cannot
compress the mesh and hence requires a larger port (12 mm) for its introduction.
GORE-TEX dual mesh:
The Gore-Tex Dual mesh (W. L. Gore, USA) material has two surfaces; one is smooth (micropores 3
and the other is rough (micropores approximately about 22 mm). It is designed to be
implanted with the smooth surface against the visceral organs - tissue to which no or minimal
adhesion is desired - and the other surface against which tissue incorporation is desired. The
Dual mesh comes in two choices: one is a solid sheet and the other is perforated to allow for
greater tissue incorporation. A recent innovation is the incorporation of silver and chlorhexidine
into the ePTFE. This results in a significant antimicrobial action.
The development of new prosthetic biomaterials with the addition of absorbable and nonabsorbable
barriers for adhesion prevention after intra-abdominal placement of mesh during open and
laparoscopic hernia repair is potentially a significant advancement in the management of ventral and
incisional hernias. Long-term follow-up is desirable to determine if Sepramesh, Parietex Composite,
Parientene Composite, PROCEED surgical, Bard Composix and Gore-Tex Dual meshes will decrease
the incidence of mesh-related complications compared to nonbarrier, macroporous meshes.

SELECTION OF MESH
For inguinal hernia repair by TAPP or TEP, following meshes can be used, Conventional
polypropylene mesh, PROLENE soft mesh, VYPRO II, ULTRAPRO

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For intra-abdominal placements, any mesh that will prevent bowel adhesions should be used. It
can be either ePTFE, PROCEED surgical mesh or any one of the newly engineered meshes with
an absorbable or a nonabsorbable barrier.
Next important to consider is the size of the mesh. It must be at least 15 × 15 cm for an inguinal
hernia. For repair of umbilical, ventral and incisional hernia, it should be at least 5 cm wider than
the defect. It is better to initially measure the size of the defect with the scale and then select a
mesh of appropriate size. It should be wide enough to cover the defect in all directions since a
smaller size may lead to protrusion of the mesh into the defect and result in a recurrence.

History
Billroth in 1878 used prostheses before Bassini’s sutured cure (1887). Phelps in1894 used silver coils.
Metals were replaced by plastic by Aquaviva in 1944. Usher in 1962 used Polypropylene with less
infection, became popular. Usher instituted tensionless, overlapping preperitoneal repair. Stoppa in
1969 championed the sutureless Cheatle-Henry approach encasing the peritoneum. His technique,
“La grande prosthese de renforcement du sac visceral” (GPRVS), was adopted by laparoscopists.
Incisional herniation has been controlled by prefascial, retrorectus prosthetic placement by Rives-
Flament in 1973. Sher et al. In 1980 used ePTFE intraperitoneally, since it evokes few adhesions.

Medical Uses
The function of surgical mesh is to support prolapsed organs either temporarily or permanently. It is
most commonly used in hernia surgery within the abdomen. Surgical mesh may also be used for
pelvic or vaginal wall reconstructions in women and is implemented to add as a growth guide for
damaged tissue.Hernia surgery is most common current applications of surgical mesh. Surgical mesh
is implanted to strengthen tissue repair and minimize the rate of recurrence.12 Polypropylene (PP) is
the most frequently used type of mesh, although it may be uncomfortable for the patient after
implantation. Another type that is less utilized in hernia surgery is polyethylene-terephtalat (PET),
which faces complications that it easily degrades after some years of implantation, erasing the effects
of the surgery. Polytetrafluorethylene (PTFE) is used as well, but is manufactured in the form of a foil
and has difficulty integrating into surrounding tissue, therefore it loses stability.13
In Pelvic surgery similar to hernia surgery, synthetic meshes may be used for organ prolapses in
the pelvic region as well. 14 Mesh surgery can be performed in various areas of the pelvic region,
such as cystocele, rectocele, and vaginal vault or uterus. The most commonly used material, as
in hernia surgery, is PP, which is considered to have acceptable biocompatibility within the
region. It induces a mild inflammatory response but has a tendency to adhere to the viscera. 15
The vaginal wall has three layers: tunica mucosa, muscularis, adventitia. When prolapse occurs,
smooth fibers of the muscularis are compromised. Prolapse in women has also been seen to
increase stiffness in the pelvis, particularly post-menopausal women.15 Surgical mesh that is
used in pelvic reconstruction must counter this stiffness, but if the modulus of elasticity is too
high, it will not sufficiently support the organs. On the contrary, if the mesh is too stiff, tissue will
erode and inflammatory responses will cause post-surgical complications.
Additionally, the mesh has enough strength to withstand basic actions and tissue behavior in
physiological conditions, particularly during tissue regeneration through the mesh itself. 15 The
area is subjected to a variety of loads approaching from abdominal contents, pressure from
abdominal/diaphragm muscles, and genital organs, as well as respiratory actions. For the
average, reproductive-age woman, the pelvis must withstand loads of 20 N in the supine
position, 25-35 N in the standing position, and 90-130 N whilst coughing.15 Any mesh that is
implanted in the pelvic area must be strong enough to withstand these loads.

MESH complication
Herniamesh can cause severe complications that predominately affect the abdominal area, intestines,
and bowels. Some of them are; Perforated intestines, Perforated bowel Intestinal fistulae, Bowel
obstruction, Bowel resection, Peritonitis, Abdominal wall tears Abscess, Sepsis, Lack of ingrowth of
mesh, Puncture of other abdominal organs, Adhesions of the mesh to material of the bowel, Hernia
recurrence, Chronic Pain, Infection, Nerve entrapment, Buildup of scar tissue

INFECTIONS
In some cases, the body can reject the hernia mesh as a foreign object, resulting in an infection.
Infections can appear as quickly as two weeks after surgery, or as long as 39 months post-surgery.
One study published in Clinical Microbiology and Infection found hernia infection rates to be as
high as 8% in patients.

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Symptoms of a hernia mesh infection can include: Pain Tenderness Swelling Increased
temperature Flushed skin Fever Chills
These infections can cause discharging fistulas (abnormal connections between two organs,
blood vessels, or intestines) and intra-abdominal abscess (collections of pus or infected fluid in
the abdomen surrounded by inflamed tissue).
Infections can often be treated with antibiotics. But, in some cases, patients will require
additional surgery to remove the surgical mesh.
The risk of infection is mainly determined by the type of filament used and pore size. Microporous
meshes (for example, ePTFE) are at higher risk of infection because macrophages and neutrophils are
unable to enter small pores (< 10 μm). This allows bacteria (< 1 μm) to survive unchallenged within the
pores. A similar problem applies to multifilament meshes. The meshes at lowest risk of infection are,
therefore, those made with monofilament and containing pores greater than 75 μm. Eradication of
infection in such meshes can be achieved without their removal.16

HERNIA MESH CAN MIGRATE AND SHRINK

The surgical mesh may shrink, stretch, or even migrate from its original position. It isn’t just the
material of the surgical mesh that can cause medical complications, but also its size and
location. Once implanted, mesh may shrink, stretch, or even migrate from its original position.
This can perforate and injure the intestines, bowels, and other nearby organs. If the weakened
tissue is left inadequately supported, the hernia can come back. Recurrent hernia repair
surgeries though are even more likely to result in complications than the first operation.

Bowel Adhesion, Obstruction

Mesh can stick to the bowel, causing the intestine to kink. Over time, this kink may result in an
obstruction.
In some cases, the mesh can even erode through the bowel.

Allergic Reactions
Some meshes, like the C-QUR, are coated with an Omega-3 gel coating. This fish oil base is
designed to reduce inflammation and prevent surrounding tissue from attaching to it. However,
the unique substance can trigger an allergic reaction in some patients.

Chronic Pain
Pain is caused by nerve compression syndrome. This is caused when too much pressure is applied to
the nerves. All meshes produce adhesions when placed adjacent to bowel, but their extent is
determined by pore size, filament structure and surface area. Heavy-weight meshes produce intense
fibrotic reaction which ensures adheres to the abdominal wall and causes dense adhesions. But,
microporous ePTFE do not allow tissue in-growth. It has a very low risk of adhesion formation, but is
unable to adhere strongly to the abdominal wall. These two illustrate difficulty of producing a mesh
which will adhere well to the abdominal wall but not bowel. Composite meshes aim to do this by
providing an additional surface which can be safely placed in contact with bowel whilst peritoneal
mesothelial cells grow over the mesh. It takes7 days to regenerate peritoneum; however, once
formed, it will prevent adhesion of mesh. Recently, the standard composite mesh was a PP/ePTFE
mix, but there are now a large variety of substances available, including PVDF, cellulose and omega-3
fatty acids. Unfortunately, there is evidence to suggest that most of these only prevent adhesion
formation in the short term and the effect is diminished after 30 days.17in some types, it is also
possible for the layers to separate and become adherent to bowel.18

RECURRENCE
Meshes are thought to reduce incidence of hernia recurrence. Reduction in the rate of
recurrence by at least half when using a mesh (like incisional hernias this is reduced from 17–
67% to 1–32%).18 Recurrent herniation occurs at the edges of meshes. This is due to inadequate
fixation, or underestimation of shrinkage of the mesh. There is little evidence that recurrence is
related to the type of mesh used.5
Although it has been proposed that light-weight meshes have a higher risk due to their increased
flexibility and movement.7 Other known risk factors include postoperative infection, seroma and
haematoma. Two-thirds of recurrences occur after 3 years (median, 26 months). 19 This suggests
that a technical error is unlikely to be the only cause of recurrence and defective collagen
synthesis may be equally important. All meshes cause a foreign body reaction which has an
effect on the ratio of Type I and III collagen synthesised.7,9

239
Changes in this ratio affect both tensile strength and mechanical stability and may increase the
risk of recurrence. Altered ratios of collagen can be seen within fibroblasts located at the edges
of recurrent hernias. It is not clear if the type of mesh used has any effect on this.
PAIN
Meshes have reduced risk of chronic pain compared to suture repair. This is thought to be related to
the ability to use tension-free technique rather than the mesh itself.19 But , pain remains a serious
complication of mesh repair .In acute postoperative pain, there is little difference in the type of mesh
used. It starts in the immediate postoperative period; it is usually due to nerve damage. In contrast,
pain due to foreign body reaction (FBR) typically presents after 1 year. Explants removed for chronic
pain have nerve fibres and fascicles around the foreign body granuloma in the mesh. Neuromas can
also be found at the interface of mesh and host tissue suggesting mechanical destruction. It follows
that meshes with small pores and greater FBR, will cause higher rates of chronic pain.
MESH DEGRADATION
Degradation of meshes is rare and mainly seen in polyester meshes. Degradation may be due to
hydrolysis, resulting in brittleness and loss of mechanical strength. Calcification can also occur
but only been seen in meshes with small pores.
SEROMA
Seromas develop in all mesh type but less likely with larger pores mesh .
References
"Information on Surgical Mesh for Pelvic Organ Prolapse and Stress Urinary Incontinence". Medical Devices
Safety Communications. Food and Drug Administration. 20 November 2012. Retrieved 2 March 2013.
Hjort, H.; Mathisen, T.; Alves, A.; Clermont, G.; Boutrand, J.P. (2012). "Three-year results from a preclinical
implantation study of a long-term resorbable surgical mesh with time-dependent mechanical
characteristics". Hernia. 16 (2): 191–197. PMC 3895198 . PMID 21972049. doi:10.1007/s10029-011-0885-y. After 36
months, the test mesh was fully resorbed]
"Vipro 2 mesh". Ethicon product guide. Ethicon. Retrieved 2 March 2013
cobb WS, Burns JM, Kercher KW, Matthews BD, James Norton H, Todd Heniford B. Normal intraabdominal
pressure in healthy adults. J Surg Res. 2005;129:231–5. [PubMed]
5 Klosterhalfen B, Junge K, Klinge U. The lightweight and large porous mesh concept for hernia repair. Expert
Rev Med Devices. 2005;2:103–17. [PubMed]
Klosterhalfen B, Hermanns B, Rosch R. Biological response to mesh. Eur Surg. 2003;35:16–20.
Koch A, Bringman S, Myrelid P, Kald A. Randomised clinical trial of groin hernia repair with titanium-coated
lightweight mesh compared with standard polypropylene mesh. Br J Surg. 2008;95:1226–31.[PubMed]
Divilio LT. Surgical adhesion development and prevention. Int Surg. 2005;90:S6–9. [PubMed]
diZerega GS, Campeau JD. Peritoneal repair and post-surgical adhesion formation. Hum Reprod Update.
2001;7:547– 55. [PubMed]
Holste JL. Are meshes with lightweight construction strong enough? Int Surg. 2005;90:S10–2.[PubMed]
Matthews BD. Absorbable and nonabsorbable barriers on prosthetic biomaterials for adhesion prevention after
intraperitoneal placement of mesh. Int Surg. 2005;90:S30–4. [PubMed]
Neumayer, Leigh; Giobbie-Hurder, Anita; Jonasson, Olga; Fitzgibbons, Robert Jr.; Dunlop, Dorothy; Gibbs, James;
Reda, Domenic; Henderson, William (2004-04-29). "Open Mesh versus Laparoscopic Mesh Repair of Inguinal
Hernia". New England Journal of Medicine. 350 (18): 1819–1827. ISSN 0028-4793. PMID 15107485.
doi:10.1056/NEJMoa040093.
13. Brown, Bryan N.; Londono, Ricardo; Tottey, Stephen; Zhang, Li; Kukla, Kathryn A.; Wolf, Matthew T.; Daly, Kerry A.;
Reing, Janet E.; Badylak, Stephen F. (2012-03-01). "Macrophage phenotype as a predictor of constructive remodeling
following the implantation of biologically derived surgical mesh materials". Acta Biomaterialia. 8 (3): 978–
987. PMC 4325370 . PMID 22166681. doi:10.1016/j.actbio.2011.11.031
todros, S.; Pavan, P. G.; Natali, A. N. (2016-03-01). "Biomechanical properties of synthetic surgical meshes for pelvic
prolapse repair". Journal of the Mechanical Behavior of Biomedical Materials. 55: 271–
285. doi:10.1016/j.jmbbm.2015.10.024
Schreinemacher MHF, Emans PJ, Gijbels MJ, Greve JW, Beets GL, Bouvy ND. Degradation of mesh coatings
and intraperitoneal adhesion formation in an experimen tal model. Br J Surg. 2009;96:305–313.[PubMed
Bohmer RD, Byrne PD, Maddern GJ. A peeling mesh. Hernia. 2002;6:86–7. [PubMed]
Schumpelick V, Klinge U. Prosthetic implants for hernia repair. Br J Surg. 2003;90:1457–8. [PubMed]
Schumpelick V, Nylus L. Meshes: benefits and risks. Berlin: Springer; 2003.

LAPAROSCOPIC HERNIA REPAIR

-Dr. Anubhav Vindal

With the advances in laparoscopy in the last 2 decades, and the advantages of minimizing the access, there
is hardly any surgery that does not have a laparoscopic counterpart. Hernia repair is one of the commonest
surgeries performed by a general surgeon. Laparoscopy is a valid alternative to traditional open techniques
for the treatment of hernias. It is associated with a lower incidence of postoperative pain, permits rapid
recovery of normal physical activity with similar success rates as with open repairs.1-4

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This discussion will deal with laparoscopic hernias under the following headings:
Laparoscopic Inguinal hernia repair
Laparoscopic Incisional and Primary Ventral hernia repair
Laparoscopic repair of other hernias

LAPAROSCOPIC INGUINAL HERNIA REPAIR

Inguinal hernia repair is the most frequently performed operation in general surgery. 5Because
inguinal hernia repair is performed so frequently, relatively modest improvements in clinical
outcomes are expected to have a significant medical impact.6
The first laparoscopic inguinal hernia repair was performed by Ger in 1982. 7 Laparoscopic inguinal hernia
repair may be performed either intraperitoneally or extraperitoneally. All these repairs are classified as
posterior repairs as the hernia is approached posterior to fascia transversalis in all the variants of
laparascopic repairs. The laparoscopic approach is based on proven principles of the placement of the mesh
in the pre-peritoneal space as advocated by Cheatle8 in 1921 and proven by Stoppa.9
The two most common types of laparoscopic inguinal hernia repair in the present day are the
Transabdominalpreperitoneal repair (TAPP) and the Totally extraperitoneal repair (TEP).

TransabdominalPreperitoneal (TAPP) Repair

The transabdominalpreperitoneal (TAPP) repair was described separately by Arregui 11and Dion12in 1992. It
involves creation of pneumoperitoneum followed by introduction of two working ports. The peritoneum is
incised cephalad to the inguinal floor and the hernia defect is dissected and reduced. Large sacs are usually
transected and the distal sac left in situ. A polypropylene mesh is placed over the entire myopectineal orifice
and may be secured to Cooper’s ligament and the underside of the conjoined tendon by sutures or
staples.Care should be taken to avoid fixation in the "triangle of doom" and the "triangle of nerves/triangle of
pain”. The peritoneal flap is then sutured back to prevent mesh adherence.
This technique has a more familiar orientation to the inexperienced surgeon. It also has an
advantage of discovering an asymptomatic contralateral hernia. However, as it is an
intraperitoneal surgery, additional care is required to prevent injury to urinary bladder, hollow
viscera, and blood vessels besides safeguarding the vas and cord structures.

Total Extraperitoneal (TEP) Repair

The first totally extraperitoneal (TEP) repair is credited to Duluqr13and McKernan14 who separately
described it in 1992. In this method, the peritoneal cavity is not entered at all. The entry is made at the
umbilicus by incising the anterior rectus sheath. A blunt trocar is inserted beneath the rectus muscle
anterior to the posterior rectus sheath to access the preperitoneal space caudal to the line of Douglas.
A balloon dissector is used to open up the preperitoneal space after which the laparoscope is inserted.
Alternatively, the tip of the laparoscope is used to bluntly dissect the preperitoneal space.
The space is further developed after placement of two working ports. Careful dissection is carried
out from the medial to the lateral side, exposing the pubic symphysis which shines to the light,
(referred to as the light house), the Hesselbach’s triangle, the inferior epigastric vessels, cord
structures and lateral space up to the psoas muscle.

The direct hernial sac reduces promptly and the indirect sac located supromedially has to be dissected
from the cord structures by blunt and sharp dissection and the sac reduced. For bilateral hernia, the
surgeon then dissects the opposite side at this stage. In case a herniotomy is carried out for large and
complete hernias, an endoloopis applied to the proximal end of the sac to prevent pneumoperitoneum.

The space created after the completed dissection should be enough for a 12x15 cm polypropylene
mesh or an appropriately sized preconfigured mesh (like the 3D mesh, CR Bard, Cranston, NJ, USA).
The mesh is placed between the underside of the abdominal wall and over the peritoneum, fixing
itmedially to the pubis. Lateral fixation entails danger of nerve entrapment and is best avoided. The
space is decompressed under vision to avoid folding of the mesh as the gas is released.

Controversies in Laparoscopic Inguinal Hernia

Repair (A) Laparoscopic versus Open repair
The National Institute of Clinical Excellence (NICE) in the UK has issued guidelines on inguinal hernia
repair in January 2001 and revised it in 2005.15 It recommends laparoscopic repair for primary inguinal
hernia as one of the options provided it is performed by an experienced surgeon conversant with the
technique.For bilateral and recurrent hernias, laparoscopy is advised and TEP is preferred. 15The
various points of comparison between open and laparoscopic inguinal hernia repairs are:

241
Operative time
Laparoscopic repairs in general take a longer time for completion compared with open
repairs. But it has been seen that in the hands of experienced surgeons, the operative
times are comparable.16
Intraoperative complications
Laparoscopic repairs carry a higher risk of complication in respect of visceral (especially
bladder) and vascular injuries.17
Post operative recovery
The time to return to usual activity has been found to be shorter in the laparoscopic
repairs. This is equivalent to an absolute difference of about 7 days.18
Cost
Laparoscopic repairs are inherently costlier than the open repairs due to the cost of the
equipment, need for general anaesthesia and longer operative times.19 However, studies have
shown that in the long run, these costs are offset by the cost savings due to faster post
operative recovery and earlier return to work.20Moreover there are reports suggesting that the
laparoscopic repairs can be performed as day care procedures in properly selected patients.21
Difficulty of technique
Laparoscopic surgery requires tremendous hand-to-eye co-ordination with restricted
maneuverability and loss of sensory and tactile feedback. Therefore it is technically more difficult
and demanding than open repair.There is evidence of a ’learning curve’ in its performance22which is
estimated to be 50 operations for the TAPP operation, and between 50 and 100 for the totally TEP
repair.23,24 However, reports25,26 have shown that the learning curve can be overcome by
performing open preperitoneal mesh hernia repair advocated by Stoppa.9
Early Post operative complications
Complications like wound infections and haematoma formation are lesser in laparoscopic
surgery.16 The mesh does not come in contact with the skin and is delivered directly
through the port at the site of fixation. The risk of seroma formation is however higher in
the laparoscopic repairs due to the more extensive dissection required. 18
Pain
Both early post operative pain as well as persisting pain and numbness are lesser in
laparoscopic repairs compared with open repairs.27 The differences are more marked in
recurrent and bilateral hernias.16,28,29
Recurrence
No differences have been observed between laparoscopic repairs performed by
experienced surgeons and the open repairs, which are considered the gold standard.30
Port-site hernia
Although rare, this complication is associated only with laparoscopic repairs, particularly
with TAPP.16
Bilateral hernias
Laparoscopic surgery allows bilateral hernias to be repaired through the same three small
incisions; there is no effective increase in postoperative pain or recovery time. 21
Recurrent hernias
The same advantages are apparent in the repair of recurrent hernias particularly when the
recurrence has occurred more than once. The laparoscopic technique occurs in virgin
territory and the recurrence rates are the same for primary and recurrent hernias. 21
Clinically occult contralateral hernias
Up to 30% of patients with a unilateral hernia will subsequently develop a further hernia on
the contralateral side.21 Also, when seen at laparoscopy, 10–25% of patients are found to
have an occult hernia on the contralateral side. 31 Both laparoscopic approaches allow
assessment and treatment of the contralateral side at the same operation without the need
for further incisions, very little further dissection and minimal postoperative pain. 32,33 In
open surgery a further large incision is required in the opposite groin, considerably
impairing postoperative mobility and the increased likelihood of admission to hospital.
However this is a controversial indication as there are no identifiable risk factors for the
development of hernia via a patent processus vaginalis and therefore it is not known what
percentage of these will transform into a clinically significant hernia requiring treatment.21
Choice of anaestheticLaparoscopic repairs are generally performed under a general
anaesthetic and therefore contraindications to general anesthesia for cardiopulmonary
reasons may preclude a patient from undergoing laparoscopic hernia repair.16,34

242
 There are, however, incidental reports of the use of epidural and local anesthesia for
TEP.35–37 These methods have not gained momentum for various reasons, but they are
part of the armamentarium for laparoscopic hernia repairs.

Open repair can be performed under local anaesthetic but this is not always acceptable to
the patient or feasible.It has been reported that up to 98% of patients with a reducible
hernia for elective repair can be safely operated upon under local anaesthesia (LA) on an
ambulatory basis.38

(B) TAPP or TEP repair?

The results of various studies indicate no difference between the two when considering operation
time, hematoma, length of hospital stay, time to return to usual activity and recurrence. 39However,
there is an evidence of increased port-site hernias and visceral injuries with TAPP and more
conversions with TEP. Vascular injuries and mesh infections do not reveal any difference.

Differences between TAPP and TEP40

Criteria TAPP TEP
Peritoneal entry Yes No
Anaesthesia GA GA or regional
Anatomy Relatively familiar Unfamiliar plane
Loss of space Not applicable Yes, if peritoneal rent
Learning curve Less steep (30 – 50) Very steep (50 – 100)
Diagnosis of bilateral hernia Easy Needs dissection
Irreducible or sliding hernia Preferred Difficult
Mesh fixation More often required Only medial fixation
Peritoneal suturing Always required Not applicable
Bowel injury More common Rare
Vascular injury Reported Rare
Trocar injury Possibility Rare
Conversions Less common More common
Recurrence Similar to TEP Similar to TAPP
Return to work Early – similar to TEP Early – similar to TAPP
Chronic groin pain Rare Rare
Port—site hernia Reported Extremely rare

(C) Mesh fixation – is it required?

The necessity of fixing mesh to prevent recurrence of hernias following laparoscopic inguinal
hernia repair is controversial.41 Repair without mesh fixation does not appear to increase the
incidence of hernia recurrence and leads to decreased hospital stays and fewer admissions for
23-hour observation compared with mesh fixation to the abdominal wall. 42Khajanchee et al43
found no increased risk of recurrence in the group in which the mesh was not fixed and that fixing
the mesh was associated with an increased risk of neuropathic complications. TEP without
fixation may not be appropriate in everyone. Lau and Patil 44 recommended that mesh fixation
should be used in patients with larger hernial defects, thereby avoiding tacks when repairing
small to medium indirect inguinal hernias and smaller direct defects.

(D) Indications for laparoscopic repair and who should be doing it?
The noncontroversial answer is bilateral and recurrent inguinal hernia. However, it may be desirable to
extend the indication to unilateral hernia in a fit and healthy person of 25 to 60 years. The laparoscopic
repairs have lesser postoperative pain, shorter hospital stay and earlier return to work. For older males
of 65 to 70, however, it may not be wise to expose them to general anesthesia when a gold standard
open operation can be performed under local anesthesia. It may, however be stated that TEP repair can
be performed under regional anesthesia in a select group, like direct hernia and small indirect hernia
where dissection is minimal. However, as peritoneal breach is a distinct possibility, general anesthesia
is preferred. TAPP repair, however, requires general anesthesia in all.40

The open hernia surgery is generally considered a basic operation and may well be relegated to
the junior most, in the operating team. The laparoscopic repair however, be it TAPP or TEP, is an
advanced skills procedure and demands high degree of expertise.

243
The space especially in TEP is limited and there are important structures around the working area
like urinary bladder, inferior epigastric artery, testicular vessels, vas deferens, iliac vessels, and
neural pathways. Strict asepsis is the prime need and infection in the space may necessitate early
mesh removal.

Unlike open surgery, laparoscopic repair has a longer and steeper learning curve and it is wise
not to embark on it independently in the earlier phase of surgeon’s laparoscopic career.
Exercising restraint is crucial to let not this surgery go into disrepute. Laparoscopic repair may
not be a procedure for an average general surgeon unless one has mastered the technique. lt is a
technically challenging procedure with a steep learning curve. Moreover, neither open, nor
laparoscopic repair can be the only way to treat all hernias. When properly performed, almost all
techniques effectively repair inguinal hernia with minimal morbidity and low recurrent rate.

LAPAROSCOPIC INCISIONAL AND PRIMARY VENTRAL HERNIA REPAIR

Abdominal wall hernias can be classified into primary ventral and incisional hernia.45 There are four main
types of primary ventral hernias: umbilical, paraumbilical, epigastric and spigelian. 46Incisional hernia is a
common long-term complication of abdominal surgery and is estimated to occur in 3% to 13% of laparotomy
incisions.47 However, its incidence is greater than 23% in patients who have developed an
infection in the laparotomy wound.48,49 Approximately 50% of incisional hernias develop within the first 2
years after the primary operation, and 74% develop after 3 years. 50,51 The recurrence rate of incisional
hernia, after primary closure is high, ranging between 10% and 50%, and has been reduced to 3%
to 18% after the introduction of prosthetic materials (meshes) in hernia repair. 47,52,53 Incisional
hernias represent about 80% of all ventral hernias.54
An increasing interest in laparoscopic surgery and the availability of new materials have encouraged the
adoption of laparoscopic techniques in incisional and primary ventral hernia repair. Laparoscopic ventral
hernia repair (LVHR) was introduced into surgical practice by LeBlanc and Booth in 1991. 55 It is based on the
same physical and surgical principles as the open underlay procedure described by Stoppa, 56 Rives,57 and
Wantz.58Placement of a large prosthesis in the preperitoneal space allows for intraabdominal force to be
dispersed over a greater surface area, which may contribute to the strength and durability of the repair. 59
Essential to the success of the laparoscopic approach is adequate mesh fixation. Current approaches to
LVHR involve fixation of the mesh with permanent transfascial sutures and tacks. 60

Technique
The laparoscopic technique has numerous variations of the methodology used by surgeons, although
several common steps are followed by all. The procedure starts with entering the peritoneal cavity by
using a Veress needle, an open Hasson method, or an optical trocar allowing view of the abdominal
wall layers during penetration and establishing a pneumoperitoneum of 12-15 mmHg. Three trocars are
used, one 10-12 mm trocar and two 5-mm, which are placed as laterally as possible on the abdominal
wall, so they are at an adequate distance from the hernial orifice. A complete adhesiolysis of the
abdominal wall, possibly the most difficult part of the procedure, is then performed. The adhesions in
the abdomen are lysed using cold scissors (preferable), electrocautery or an ultrasonic scalpel. Once
adhesiolysis has been completed, full visualization of the abdominal wall provides an additional
technical advantage of visualization of small clinically occult fascial defects (“Swiss cheese”). The sac
contents are then gently reduced into the peritoneal cavity, while the peritoneal sac is left in situ.

The periphery of the hernia defect is evaluated by direct vision and palpation and is marked on the
abdominal wall skin with a marker. The carbon dioxide should be released prior to measurement,
revealing the true size of the hernia defect. The cranio-caudal and lateral measurements are taken
to define the size of the prosthetic mesh. The surgeon should add 5 cm to these measurements in
both directions, which provides an adequate overlap of the aponeurotic edges of the hernia by the
mesh. Some surgeons suggest a 10cm overlap, especially if the patient is morbidly obese, or if
the hernia is recurrent or of large size.61 The size of mesh that most closely approaches this
measurement is selected for the repair.

After selection of the appropriate-sized mesh, 4 to 6 sutures are placed on the edges of the
prosthetic mesh. The prosthetic mesh is rolled tightly and inserted in the peritoneal cavity
through the 10-12 mm trocar. It is unrolled inside the abdomen and spread under the defect to
ensure adequate overlap beyond all areas of fascial defect. The mesh is then secured in place to
prevent migration and chances of recurrence.

244
For this either metallic tacks, permanent or absorbable polymeric helical fasteners, strap devices or
sutures can be used.62 For placement of the trans fascial sutures, two-mm skin incisions are made on
the abdominal wall. With the help of a Bercifascial closure instrument (KARL STORZ GmbH & Co. KG,
Tuttlingen, Germany) or the Endoclose (Autosuture) inserted through each skin incision into the
peritoneal cavity, the 2 ends of each suture pre placed on the mesh are grasped and drawn outside
through the skin incisions by separate passages and at different angles. The suture ends are tied down
extracorporeally and buried subcutaneously. The spiral/helical/strap devices are placed in the form of
two concentric circles, one at the periphery of the mesh, and the other one surrounding the fascial
defect (“Double Crown”), spaced around 2 cm from each other and 1 cm from the margin of the mesh.

Controversies in Laparoscopic Ventral Hernia

Repair (A) Laparoscopic versus Open repair
LVHR achieves adequate closure of the hernia defect by using intra-peritoneal mesh fixation with
minimal soft tissue dissection. The technique has all the advantages of the laparoscopic
approach. By placing the mesh intra-peritoneally, the intra-abdominal pressure pushes upwards
and holds the mesh into position. However, there are some points of comparison when choosing
between open and laparoscopic approaches.

Operative Time& Cost

Perceived disadvantages of laparoscopic incisional hernia repair are longer operating
times and the increased cost of equipment and expensive specialized mesh.
In fact, several retrospective and prospective comparative studies have shown that the
laparoscopic approach does not take longer in experienced hands. 63,64The increased
procedural cost is compensated by several factors like faster recovery and lower re-
admission rates, reducing the costs of bed occupancy. Lower recurrence rates might
reduce the need for repeat surgery.
Post operative recovery
Several studies have suggested that LVHR is associated with less postoperative pain, earlier
recovery, and a shorter convalescence period compared with the open techniques. 65The
patients feel more comfortable and tolerate oral intake earlier than after the open procedure.
Open surgery requires considerable soft tissue dissection. Large incisions and extensive
dissection may result in considerable postoperative pain, ileus, wound haematoma and wound
infection, all contributing to prolonged hospital stays, delayed return to normal activities and
increased risk of deep venous thrombosis/pulmonary embolism.
Meta-analyses have shown that length of hospital stay is shorter by 2–3 days and carries lower
complication rates.46,64Laparoscopic repair can often be successfully carried out in a day-case
setting and rates of re-admission to hospital are lower after laparoscopic surgery.65-67
Intra operative complications
The laparoscopic approach carries the risk of intestinal or bladder injury
intraoperatively.68 Adhesions to the abdominal scar represent a significant problem during
LVHR, with the risk of bowel injury around the neck of the hernia during dissection. Injury
of a hollow organ is a very serious event and should be recognized and treated
immediately. An incidental enterotomy may occur during initial trocar placement or may
result from adhesiolysis. If the enterotomy remains unnoticed, it may result in an acute
abdominal condition and sepsis within a few hours after surgery.
Post operative pain
Series have demonstrated lesser or comparable postoperative pain for laparoscopic
andopen approaches.69Chronic pain lasting beyond 12 weeks at the site of a
transabdominal suture has been reported and has an incidence of 1.3% to 3.3%. 59,70,71
Seroma formation
The commonest complication of laparoscopic incisional hernia repair is seroma formation
at the site of the hernia (10–50%) as the hernia sac is left in situ.72 The incidence of
seroma can be reduced by the use of compression bandages or binders that can be worn
by the patient for up to 10 days’ postoperatively. The majority of seromas resolve naturally
and require no treatment; those that persist or cause significant discomfort may be
aspirated, but only 2–5% require intervention.72
Infection
In LVHR, the mesh comes into minimal contact with the patient’s dermal flora while it is
introduced intraperitoneally. Minimal tissue dissection in the laparoscopic approach
further reduces the risk of infection.69

245
 Clinically occult hernia
As described earlier, with laparoscopic approach, minimal fascial defects, known as
“Swiss cheese” defects, which may be missed during the open repair, can be identified
and closed with one mesh.69 Clinical examination is often misleading because multiple
defects may be associated with a single incisional hernia. This may be the reason of the
lower rates of recurrence of the laparoscopic technique. These defects when missed, may
present as a site of recurrence at a later date.72
Cosmesis
The main disadvantage of the laparoscopic approach is that the hernia sac is usually retained
in place and in case the scar is ugly, offers limited cosmetic advantage to the patient. On the
other hand, the scar can be excised in an open repair, giving excellent cosmetic results.
This can be dealt with by using the hybrid techniques, where the sac and the scar are excised by the
open approach followed by the intraperitoneal mesh placement by the laparoscopic approach.
Loss of domain
The components’ separation is a simple procedure which detaches the external oblique
from the rectus muscle allowing upto 10-cm advancement into the midline on each side of
the abdomen.72 This confers a spherical shape to the abdominal cavity and increases
capacity allowing return of viscera without risk of abdominal compartment syndrome. 73
This procedure was not available to the laparoscopic surgeon till recently. However, many
reports have now shown good results with laparoscopic component separation
technique.74The procedure is still evolving and has several varaitions.
Recurrences
Sainset al75 noted a trend towards lower hernia recurrence rates following the
laparoscopic approach. Pierce et al76 demonstrated a significantly lower recurrence rate
with LVHR compared with OVHR series. Although recurrence can still occur after LVHR, it
does not surpass 5% to 10% in most series.69

Methods of Fixation
Mesh Fixation with Tacks and Sutures
A variety of reports are available on this type of mesh fixation, which represents the
traditional technique in LVHR. LeBlanc et al67 have also suggested the importance of
suture anchorage at 4-cm to 5-cm anchorage intervals around the perimeter of the mesh to
minimize the risk for mesh migration. Both absorbable and permanent sutures had greater
fixation strength than metallic tacks, although absorbable sutures had a significant loss of
strength compared with permanent sutures at eight weeks.59
Mesh Fixation With Tacks Alone
Several studies have claimed the efficiency of tack-alone mesh fixation in LVHR. However,
there is a general idea that tacks do not have the same holding strength as full-thickness
abdominal sutures.69 Experimental studies have also demonstrated the superiority of
transabdominal sutures compared with tacks for mesh fixation. Series have shown early
recurrences when metallic tacks alone were used for fixation.77,78
Soft Fixation with fibrin glue
Few reports of soft fixation of mesh using fibrin glue have shown promising results with
reduction in early post operative pain compared to fixation with tacks and sutures. 69 Long
term results on the rates of recurrences using this approach are awaited.
Choice of Mesh
Several types of mesh have been used for ventral hernia repair: the first generation or the uncoated meshes,
the second generation or the tissue separating (barrier) meshes and the third generation or the biological
meshes.The uncoated meshes are no longer used in the laparoscopic approach, because it may create
adhesions with bowel loops. These are replaced by the more popular and the most commonly used barrier
meshes. Several varieties and brands are available, each with its own distinctive properties. The choice of a
particular mesh is largely dependent on the surgeon’s preference. The third generation biological meshes
are the most recent addition to the armamentarium. These have been treated to eliminate all cells and
proteins other than collagen, which may evoke adverse reactions to the host. There is no clear indication for
the use of these meshes although some studies have shown that these meshes tolerate infection better than
the second generation meshes, and therefore may have advantage when used in a contaminated field (post
accidental enterotomy in LVHR).
There are no long-term clinical or experimental data to support the use of most mesh products
presently in use. Hence it is difficult to advocate the use of any particular type of mesh over another.

246
LAPAROSCOPIC REPAIR OF OTHER HERNIAS
Suprapubic Hernias, Lumbar Hernias and Hernias near the Iliac Crest
Historically, periosteal suture fixation has been used to secure the mesh during open suprapubic
hernia repairs. Studies have shown that lack of secure fixation of mesh in the suprapubic position
has led to an increased rate of recurrence in Laparoscopic repairs. 79 The lack of fascia in this
location has generated a need for an alternative method for secure fixation. Bone anchors have
been safely used in orthopedic surgery for many years, and the pull-out strength of suture bone
anchors is superior to that of simple periosteal suture fixation. 80 Suture bone anchors allow a
firmer attachment of the mesh to stronger bony or ligamentous structures, as opposed to muscle
at the hernia’s border. Those results prompted the use of bone anchors for suprapubic hernias as
well, because recurrences tend to be at the inferior location over the pubic bone.81

Technique
The entire preperitoneal space is dissected to identify the pubis, the Cooper ligament bilaterally,
and the inferior epigastric vessels. This allows for placement of the mesh with good overlap and
avoidance of neurovascular injuries. The mesh can then be secured to the Cooper ligament with
tacks and secured with additional bone anchors placed in the pubis. The same type of anchors
can be applied for hernias near the anterior iliac spine.82

Parastomal Hernias
Parastomal hernias present a particularly challenging problem because the stoma itself must remain a
defect despite repairing the hernia. Traditional surgical management has consisted of local tissue
repair, stoma relocation, or placement of a prosthetic mesh.83-86 Hernia recurrence rates for primary
fascial closure are reported to range from 46% to 100%. 83-86 Stoma relocation is reported to have a
hernia recurrence rate of 36% (range, 0%–76%)85,86 but may require an additional laparotomy.

Open repair with polypropylene mesh has improved these outcomes, but it is still associated with a failure
rate of 26% to 29%.82 Overall complication rates of up to 88%,85 combined with a growing number of reports
of decreased patient morbidity and improved outcomes with laparoscopic tension-free mesh repair of ventral
hernias, have led many surgeons to apply these techniques to this difficult problem.

Two main techniques have been employed: Keyhole and Sugarbaker.

Sugarbaker technique
Paul H Sugarbaker84,87 was the first to describe the placement of intraperitoneal mesh for the repair of
parastomal hernias. His technique involved placing a piece of mesh around the fascial defect and
securing it circumferentially, except laterally where the colon exited the abdominal cavity to create a
mesh flap valve around the stoma to help prevent further herniation. He advocated laparotomy for
placement of the mesh to avoid contact with the stoma bud and thus reduce infection.

Keyhole technique
In contrast, with the keyhole technique, a 2- to 3-cm keyhole defect is created in the mesh to
accommodate the ostomy without the creation of a flap valve as described by Sugarbaker.
Additional interrupted sutures are placed intra- or extracorporeally along the linear defect in the
mesh leading away from the ostomy.84

Which is better?
Sugarbaker technique has been found to be technically less demanding, associated with decreased
surgery duration, and decreased recurrence rates.88 Although the laparoscopic approach to the repair
of parastomal hernias is relatively novel, several series have been reported that had promising
shortterm results. Laparoscopic parastomal hernia repair seems to offer a good alternative to open
repair, with acceptable complication rate and low recurrence in the short term.

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 DIAGNOSTIC LAPAROSCOPY

-Dr. Lovenish Bains, Dr. Pawan Lal

BACKGROUND
The advent of laparoscopic surgery represents a landmark in surgery that initiated a shift from the
era of open abdominal surgery to the minimally invasive surgery revolution. Today, laparoscopy
is the most common and preferred method for addressing a number of routine and complex
surgical procedures, such as cholecystectomy, appendectomy, splenectomy, adrenalectomy, and
others. Whereas the use of laparoscopic techniques has primarily occurred over the last two
decades, its development spans three centuries.
Diagnostic laparoscopy (DL), also termed Exploratory laparoscopy is a minimally invasive method for the
diagnosis of intra-abdominal diseases through direct inspection of intra-abdominal organs. Diagnostic
laparoscopy also allows tissue biopsy, culture acquisition, and a variety of therapeutic interventions.
Laparoscopic ultrasonography (LUS) can also be performed during exploratory laparoscopy to evaluate
organs that are not amenable to inspection.The main advantages of diagnostic laparoscopy over traditional
open laparotomy are reduced morbidity, decreased postoperative pain& shorter hospital stay.Diagnostic
laparoscopy should be performed by physicians trained in laparoscopic techniques who can recognize and
treat common complications and can perform additional therapeutic procedures when indicated. Diagnostic
laparoscopy is useful for making a definitive clinical diagnosis whenever there is a diagnostic dilemma even
after routine diagnostic workup, including patients with nonspecific abdominal pain, hemodynamically stable
patients who have sustained blunt/penetrating trauma with suspected intra-abdominal injuries, and critically
ill intensive care unit (ICU) patients with suspected intra-abdominal sepsis or pathologies.Diagnostic
laparoscopy is an extremely useful staging tool in patients with intra-abdominal cancers (eg, esophageal,
gastric, pancreatic, gallbladder, or bile duct cancer; solitary/resectable liver metastasis; lymphoma). By
enabling accurate staging, diagnostic laparoscopy permits patient selection for curative resection or a
neoadjuvant chemotherapy while avoiding nontherapeutic laparotomy, which is associated with a delay in
initiation of chemotherapy.

HISTORICAL PERSPECTIVE
In 1901 Kelling, a surgeon from Dresden, performed the first successful laparoscopy in a dog before
theSeventy-third Congress of German Naturalists and Physicians. He anesthetized an area of the
abdominalwall and introduced a puncture needle through which room air (filtered by sterile cotton) was
injected into theperitoneal cavity to produce a pneumoperitoneum. He then introduced a larger trocar
and introduced a Nitzecystoscope through it. Through a second trocar site, he inserted a probe to
manipulate the contents of the abdominal cavity. A more detailed report was to follow but was never
published. Later, in 1910, Jacobaeus described the technique in humans afflicted with ascites. After
experimenting on 20 cadavers with a trocar he invented, he performed laparoscopy on 17 patients with
ascites and thoracoscopy on 2 patients with empyema. He did not introduce air through a separate
needle, as did Kelling, instead insufflating air through the original trocar.He advocated the technique as
an “early” diagnostic tool for malignancy. The first laparoscopy in the United States was performed in
1911 by Bertram Bernheim, a surgeon at Johns Hopkins. He was apparently unaware of the work of
Kelling and Jacobaeus. He utilized a 0.5-in.-diameter proctoscope through an epigastric incision. No
pneumoperitoneum was used; however, he reported visualizing stomach, gallbladder, liver, and
peritoneum. The first large-scale series of diagnostic laparoscopy in humans was presented in the
United States in 1920 by Orndoff. He described 42 cases of “peritoneoscopy” in the Journal of
Radiology. He described the then novel pyramidal trocar blade and utilized fluoroscopy to decrease
visceral injury during trocar insertion. In 1928, Kalk and Bruhl described one of the first large-scale
reports of laparoscopy. Ruddock, in 1937, demonstrated the efficacy and safety of diagnostic
laparoscopy with a report of 500 patients without a single mortality. Since the founding work of these
and other pioneers, diagnostic laparoscopy has slowly evolved into an invaluable tool for the diagnosis
of intra-abdominal and pelvic disease.
Diagnostic laparoscopy has been in the armamentarium of the gynecological surgeon for many years.

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Recognized more than 30 years ago by gynecologists as a useful technique for evaluating pelvic pathology,
diagnostic laparoscopy now is one of the most frequently performed gynecological procedures. However,
diagnostic laparoscopy has only recently been embraced by the general surgeon. Before the laparoscopic
cholecystectomy, which caused a revolution in general surgery, few general surgeons utilized the technique.
Increasingly, general surgeons are using laparoscopic techniques for the diagnosis of a wide range of
abdominal diseases. The application of the laparoscopic technique to the treatment of many of these
diseases has accelerated the use of laparoscopy as a diagnostic tool.
The use of laparoscopy in the diagnosis of abdominaldiseases has rapidly expanded over the last
few years. Surgeons are now expanding the role of the laparoscopeto include preoperative
staging of a wide range of cancers, post treatment or second-look laparoscopy fornumerous
malignancies, liver disease, and ascites. The number of treatment options available through the
laparoscope is also increasing rapidly.

INDICATIONS
The indications for laparoscopy are numerous and still expanding. However, the widely accepted
indications of diagnostic laparoscopy are listed below:
A. Diagnostic laparoscopy for acute conditions
Acute abdomen
Trauma
ICU

B. Diagnostic laparoscopy for chronic conditions

Chronic pelvic pain and endometriosis
Liver disease (including cirrhosis)
Infertility
Cryptorchidism
Evaluation of Ascites of unknown cause
Second-look &post treatment evaluation
Evaluation of hernias in doubtful cases
Obtaining tissue for histopathological diagnosis
Others

C. Staging laparoscopy for cancer

Pancreatic and periampullary cancers
Gastric cancer
Esophageal cancer
Liver cancer
Biliary tract cancer
Colorectal cancer
Lymphoma
CONTRAINDICATIONS
Patient selection for diagnostic laparoscopy with identification of relative or absolute
contraindications is vital to a successful outcome of laparoscopic procedure.
Absolute contraindications for exploratory laparoscopy include the following:
Known or obvious indication for therapeutic intervention, such as perforation, peritonitis,
known intra-abdominal injury, complications of previous surgery, shock, evisceration, or
abdominal wall dehiscence
Acute intestinal obstruction associated with a massive (>4 cm) bowel dilatation, which may
obscure the laparoscopic view and increase the likelihood of bowel injury
Uncorrected coagulopathy
A tense or distended abdomen (with suspected intra-abdominal compartment syndrome)
Trauma with hemodynamic instability or a clear indication of bowel injuries, such as
presence of bile or evisceration
Severe cardiopulmonary disease

Relative contraindications for diagnostic laparoscopy include the following:

ICU patients who are too ill to tolerate pneumoperitoneum, potential hypercarbia, or general
anesthesia
Presence of anterior abdominal wall infection (cellulitis or soft-tissue infection)

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 Recent laparotomy (within 4-6 weeks) or extensive adhesions secondary to previous
abdominal surgery
Aortoiliac aneurysmal disease (may be associated with increased risk of vascular
rupture) Pregnancy (may be associated with injury to gravid uterus or fetal distress)
Cardiopulmonary
compromise Morbid obesity
Limited laparoscopic
expertise Late pregnancy.
(The final decision is determined bythe clinical condition of patients, and by the surgeon’sjudgement.)

ROLE, CURRENT STATUS & RECOMMENDATIONS

Diagnostic Laparoscopy for Acute Abdominal Pain
Acute abdominal pain is one of the most common indications for an emergency department visit. In 30-
40% of these patients, the etiology of the abdominal pain remains elusive despite laboratory and
radiologic investigations. The most common indication for emergent abdominal operation or
diagnostic laparoscopy is suspected appendicitis. Traditionally, these patients have been treated with
either an open exploratory laparotomy for conditions the patient was presumed to have or active
observation. Unfortunately, these approaches were often associated with prolonged hospital stays,
increased numbers of radiologic imaging studies and laparotomies with negative findings, and patient
dissatisfaction if the diagnosis could not be established. Laparoscopy has been applied by multiple
authors in the diagnosis of non-specific acute abdominal pain, which is defined as acute abdominal
pain of less than 7 days duration where the diagnosis remains uncertain after baseline examination and
diagnostic tests. The rationale for the use of DL in this setting is to prevent treatment delay and its
potential for disastrous complications and at the same time to avoid unnecessary laparotomy, which is
associated with relatively high morbidity rates (5-22%).
In this setting, diagnostic laparoscopy is the preferred next step in management because it
permits the following:
Visualization of the entire abdominal cavity
Localization of intra-abdominal pathology
Acquisition of peritoneal fluid for cultures or cytology
Ability to irrigate the peritoneal cavity to decrease contamination
Specific therapeutic intervention, such as laparoscopic cholecystectomy, appendectomy, or
other curative procedures

As a result of these capabilities, exploratory laparoscopy results in an improved diagnosis rate, as

well as reductions in nontherapeutic laparotomies, number of radiologic studies performed,
delayed initiation of treatment, and overall length of hospital stay.

Benefits Risks

Reduction in the rate of negative and Delay to definitive treatment with potentially
nontherapeutic laparotomies (with a increased morbidity when the study is false
subsequent decrease in negative
hospitalization, morbidity, and cost after Procedure- and anesthesia-related
negative laparoscopy) complications
Earlier diagnosis and intervention with
potentially improved outcomes compared
with observation
Ability to provide therapeutic intervention

Many studies have demonstrated high diagnostic accuracy for the procedure (70-99%). In a level I
evidence study, the diagnosis was established with early laparoscopy in more patients with non-
specific abdominal pain compared with an observation group (81% vs. 36%, respectively; p<0.001).
Regarding the utility of exploratory laparoscopy for patients with nonspecific abdominal pain, a meta-
analysis of four randomized control trials (N=811) comparing exploratory laparoscopy with active
observation concluded that early diagnostic laparoscopy was associated with a decreased number of
patient discharges without a final diagnosis. Length of hospital stay (LOS) and readmission rate were
also decreased in the diagnostic laparoscopy group; however, these changes did not reach statistical
significance.Morino et al conducted a randomized study involving 522 patients with nonspecific
abdominal pain who underwent either diagnostic laparoscopy (group 1) or observation (group 2).

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They found that early exploratory laparoscopy decreased the number of radiologic investigations (114
in group 1 vs 554 in group 2) and resulted in fewer patients without a clear diagnosis (4.2% in group 1
vs 34.7% in group 2). Equally notable, overall morbidity was 1.1% in group 1 and 27% in group 2, and
LOS was significantly shorter in the former (3.1 vs 7.3 days). Eight patients in group 1 required
readmission (46 total readmission days), compared with 58 in group 2 (201 total readmission days). In a
nonrandomized prospective study, Golash et al reported on 1320 consecutive patients with acute
abdominal pain who underwent diagnostic laparoscopy within 48 hours of admission.
A definitive diagnosis was made in 90% of patients after diagnostic laparoscopy, of which 30%
underwent a therapeutic procedure. These authors concluded that diagnostic laparoscopy
reduced unnecessary laparotomy and improved diagnostic accuracy in this population.

Recommendations
Diagnostic laparoscopy is technically feasible and can be applied safely in appropriately
selected patients with acute non-specific abdominal pain (grade B).
The procedure should be avoided in patients with hemodynamic instability and may have
a limited role in patients with severe abdominal distention or a clear indication for
laparotomy (grade C).
The procedure should be considered in patients without a specific diagnosis after
appropriate clinical examination and imaging studies (grade C).

Diagnostic Laparoscopy for Trauma

Diagnostic laparoscopy is uniquely useful in the evaluation of hemodynamically stable trauma patients
(blunt or penetrating). It can provide accurate diagnosis of intra-abdominal injuries, thereby reducing
nontherapeutic laparotomies and associated complications. In some cases, therapeutic procedures can be
performed, depending on local expertise and extent of additional injuries.Exploratory laparotomies in trauma
patients with suspected intra-abdominal injuries are associated with a high negative laparotomy rate and
significant procedure-related morbidity.Diagnostic laparoscopy may also prove useful to evaluate
diaphragmatic injury in patients with penetrating trauma to the thoracoabdominal region.
Diagnostic laparoscopy in trauma patients is typically performed with the patient under general
anesthesia.The sensitivity, specificity, and diagnostic accuracy of the procedure when used to
predict the need for laparotomyare high (75-100%). Studies of DL for trauma report negative
procedures in a median 57% (range, 17-89) of patients, sparing them anunnecessary exploratory
laparotomy. On the other hand, the median percentage of negativeexploratory laparotomies after a
positive DL (false positive rate) is reported to be around 6% (range, 0-44).

Recommendations
Diagnostic laparoscopy is technically feasible and can be applied safely in appropriately selected
trauma patients (grade B). The procedure has been shown to effectively decrease the rate of
negative laparotomies and minimizepatient morbidity.

Diagnostic Laparoscopy in the ICU

The use of DL in ICU patients has been for the diagnosis of suspected intra-abdominal pathology in critically
ill patients without the needfor transport to the operating room with its potential complications. Furthermore,
such an approach allows for theuninterrupted treatment of the ICU patient and may minimize the cost of the
intervention. Critically ill patients with suspected intra-abdominal pathology pose a uniquely difficult
diagnostic problem. The most common indication for diagnostic laparoscopy in an ICU patient is suspected
intra-abdominal pathology in a patient with unexplained sepsis.
A bedside diagnostic laparoscopy, which can be performed within the ICU, often with local anesthesia
or IV sedation, is ideal for these patients in that it can expedite the diagnosis, enable therapeutic
intervention, and avoid the morbidity of a negative laparotomy in patients who are already ill. However,
not all pathologies are readily identifiable with exploratory laparoscopy. Conditions involving the
retroperitoneum, including pancreas, perinephric area, and kidneys, may be missed with DL. DL has
demonstrated excellent accuracy in the diagnosis of more common etiology of ICU-related sepsis,
such as ischemic bowel, intra-abdominal abscess, perforated viscus, and acalculous/gangrenous
cholecystitis. Although minimally invasive surgery has expanded extensively in the past two decades,
adaptation of this technique in ICU patients, despite multiple indications has been reported in rare case
series (N=150). Whereas exploratory laparoscopy in this setting succeeded in decreasing the number
of nontherapeutic laparotomies in 36-95% of patients, mortality has remained unchanged (58-100%),
probably as a consequence of patients’ underlying critical illnesses.In two large published series, Peris
et al and Karasakalides et al reported on ICU patients who underwent diagnostic laparoscopy.

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In the series from Peris et al (N=32), bedside diagnostic laparoscopy was performed after an
average ICU stay of 8 days, and the mean procedure time was 40 minutes. Diagnostic laparoscopy
identified the source of intraabdominal pathology in 15 patients, of whom 13 subsequently
underwent a definitive surgery. In the series from Karasakalides et al, of the 35 ICU patients in
whom bedside diagnostic laparoscopy was performed, 20 (57.1%) avoided a negative laparotomy.
Large-scale randomized trials are needed for further validation.

Benefits Risks

Expeditious diagnosis of suspected Delay in the diagnosis and treatment

intra-abdominal pathology of patients if the procedure is false
Minimization of treatment interruption by negative
not moving the patient outside the ICU Missed pathology and its associated
Avoid the morbidity of open exploration complications
Avoid potential risks associated with Procedure- and anesthesia-related
transportation to the operating room complications
or radiology for diagnostic tests
Abilityto provide therapeutic
intervention

The diagnostic accuracy of the procedure is high, ranging between 90 and 100% in the published
series. The procedureappears to have excellent accuracy when evaluating for two of the most prevalent
diseases in this population,acalculous cholecystitis and ischemic bowel. The procedure has been
reported to preventunnecessary laparotomies in 36-95% of patients.Diagnostic laparoscopy has been
compared with diagnostic peritoneal lavage and found to have superior diagnostic

Recommendations
Diagnostic laparoscopy is technically feasible and can be applied safely in appropriated
selected ICU patients (gradeB).
The procedure should be used in critically ill patients when an intra-abdominal
catastrophe is suspected butcannot be ruled out by non-invasive means and would
otherwise require an exploratory laparotomy (grade C).
Itshould be given strong consideration in ICU patients with suspected acalculous cholecystitis
or ischemic bowel, asits accuracy likely exceeds that of non-invasive studies (grade C).
Diagnostic laparoscopy for chronic conditions
Chronic pelvic pain
Chronic pelvic pain, defined as pelvic pain lasting more than 6 months, is a complex disorder with
multiple underlying etiologies that range from endometriosis and adhesions to pelvic inflammatory
disease (PID). Diagnostic laparoscopy permits direct visualization of pelvic structures, allowing
identification of common etiologies, including endometriosis, adhesions, and ovarian cysts. Diagnostic
laparoscopy has been demonstrated to identify endometriosis, adhesions, or other abnormalities of the
appendix and ovaries as the source of chronic pelvic pain [3].
In patients with clinical suspicion of endometriosis, DL has been shown to confirm the diagnosis
in 78-84% of patients. For pelvic inflammatory disease, the visual accuracy of DL alone was found
to be 78% (sensitivity 27% and specificity 92%).

Benefits Risks

Potential identification of the source of Procedure- or anesthesia-related

the chronic pelvic pain complications
Possibility for immediate therapeutic
intervention
Potential improvement in the
patient’s quality of life

Recommendations
Diagnostic laparoscopy can be safely applied in the diagnosis of chronic pelvic pain (grade B).
The procedure mayidentify the etiology of chronic pelvic pain in a proportion of patients, and its
diagnostic accuracy may be improvedby the technique of conscious pain mapping (grade B).

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Primary and Secondary Infertility
Laparoscopy is typically the final step of a workup for infertility and is used to avoid open
surgery. Diagnostic laparoscopy is often combined with hysterosalpingography to evaluate
patency of fallopian tubes, during which a therapeutic intervention can also be undertaken. The
diagnostic yield of the procedure for infertile women after negative hysterosalpingography has
been describedto range between 21 and 68%.
Identified pathology includes intrinsic tubal disease (3-24%), peritubal adhesions (18-43%), and
endometriosis (up to 43%). The procedure has been described to have a higher yield in secondary
infertility (54%) compared with primary infertility (22%).
Recommendations
Diagnostic laparoscopy can be used safely in female patients with infertility (grade B).
Diagnostic laparoscopy maybe considered in appropriately selected infertile patients even
after normal hysterosalpingograms, as importantpelvic pathology may be identified in a
significant number of patients (grade C).

Non-palpable Testicle (cryptorchidism)

Laparoscopy has been used since 1976 for the evaluation of the non-palpable testis in pediatric
patients. Diagnostic laparoscopy is indicated when findings from initial inguinoscrotal exploration are
nondiagnostic. The rationale for the procedure has been to decrease the morbidity of open standard
surgical exploration for the nonpalpable testicle. Diagnostic laparoscopy identifies the location of a
nonpalpable testis with 99-100% accuracyand nontherapeutic laparotomy was avoided in 15-30% of
patients. Laparoscopic examination also provides information essential for therapeutic planning,
including length and point of entry of the vas deferens, presence of malignant transformation, and
status of opposite testis (if undescended). If necessary, therapeutic intervention (orchidectomy or
orchidopexy) can be performed laparoscopically in the same setting.

Recommendations
Patients undergoing DL for nonpalpable testis should have physical examination of the
groin under anesthesiabefore the procedure is started as this approach will identify up to
18% of testicles and obviate the need for theprocedure (grade A).
Diagnostic laparoscopy should be part of the treatment algorithm of patients with
nonpalpabletestis as it is likely to improve patient outcomes; however, further higher
quality study is needed. (Grade C).

Liver Diseases
Diagnostic laparoscopy is used to evaluate or obtain biopsy in patients with abnormal liver function test
results (liver diseases) after nondiagnostic findings from radiologic investigations. It is particularly useful in
patients with liver cirrhosis for establishing histopathologic confirmation, grading severity of illness, and
evaluating and performing biopsy on lesions that are difficult to access percutaneously. Other indications
include diffuse liver diseases (related to HIV or hepatitis virus, hepatomegaly of unknown etiology, or portal
hypertension) and liver masses (to rule out metastatic cancer, hepatoma, or benign masses). The procedure
leads to the correct diagnosis in 91% of patients and requires biopsy in most cases. Thesensitivity and
specificity of the procedure have been reported at 100% and 97%, respectively for the diagnosis ofliver
cirrhosis.The diagnostic yield of the procedure depends on the disease process (chronic liver disease 98%,
cancer 85%,ascites 82%, abnormal liver function tests 91%, HIV-related abnormal liver function tests 81%,
and hepatomegaly,splenomegaly, unexplained portal hypertension, fever of unknown origin, or cholestasis
74%).LUS can further improve the accuracy of diagnostic laparoscopy.
Recommendations
Diagnostic laparoscopy can be performed safely in patients with liver disease (grade B).
It should be considered forthe diagnosis or the grading of liver disease when other less
invasive modalities fail to provide a diagnosis or areassociated with a high bleeding risk in
coagulopathic patients (grade C).

Other
Diagnostic laparoscopy has been applied to many clinical conditions in addition to the ones
included in theseguidelines. Nevertheless, the available literature for such conditions is scarce,
consists mainly of case reports, and more data is required for understanding.
Staging of intra-abdominal cancers
A significant percentage of intra-abdominal cancers prove to be inoperable because of metastatic or
locally advanced disease despite a preoperative workup suggesting a potentially resectable disease.

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Historically, these patients would have undergone morbid negative laparotomies with associated
complications and the resultant delay in the initiation of adjuvant or palliative chemotherapy. Diagnostic
laparoscopy for accurate staging of intra-abdominal malignancies is referred to as staging laparoscopy and
is performed as a standard part of the staging workup for an increasing number of cancer subtypes. Staging
laparoscopy is useful in the evaluation of intra-abdominal malignancy in the following aspects:
Accurate staging of the tumor
Avoidance of nontherapeutic laparotomy in patients with metastatic diseases
Means of excluding metastatic disease and obtaining tissue biopsy prior to the initiation of
neoadjuvant chemotherapy
Means of obtaining tissue for diagnosis (lymphomas) or performing peritoneal lavage
cytology to exclude the presence of occult peritoneal metastasis
Identification of patients with locally advanced disease (fixed tumor or vascular invasion)
when there is no evidence of distant metastasis
Selection of appropriate palliative treatment in patients with advanced or metastatic disease
Prior to definitive laparotomy after completion of neoadjuvant chemotherapy to assess
treatment response or disease progression

Indications Contraindications (Absolute or Relative)

As a staging procedure Known metastatic disease
For detection of imaging occult metastatic Inability to tolerate pneumoperitoneum or
disease or unsuspected locally advanced general anesthesia
disease in patients with resectable disease
based on preoperative imaging prior to
laparotomy
For assessment prior to administration of neo- Multiple adhesions/prior operations
adjuvant chemoradiation
For selection of palliative treatments in patients
with locally advanced disease without evidence
of metastatic disease on preoperative imaging

Pancreatic adenocarcinoma
Surgery is the only modality that can lead to cure; however, most patients present with inoperable disease.
The overall 5-year survival is <5%. Patients with localized disease have a 15% 5-year survival after curative
resection. Despite advances in preoperative imaging (including CT, endoscopic ultrasonography [EUS],
magnetic resonance imaging [MRI], and positron emission tomography [PET]), 11-48% of patients are found
to have unresectable disease during laparotomy. For this reason, many authors have introduced SL in the
treatment algorithm of pancreatic adenocarcinoma patients in an effort to decrease the number of
unnecessary laparotomies.Large tumor size, pancreatic adenocarcinoma as opposed to periampullary
cancer or duodenal cancer, body and tail location, and preoperative CA 19-9 serum levels higher than 150
U/mL are associated with a finding of metastatic cancer at the time of staging laparoscopy.The median
sensitivity (range), specificity, and accuracy of diagnostic laparoscopy in identifying imaging-occult,
unresectable pancreatic adenocarcinoma are 94% (93-100%), 88% (80-100%), and 89% (87-98%) respectively.
Laparotomy with negative findings can be avoided in 4-36% of patients, but not in all cases; 5-7% of patients
believed to be resectable on the basis of diagnostic laparoscopy findings are found to have unresectable
tumors at the time of open exploration, typically attributable to occult vascular invasion, fixed tumors, or
presence of lymph node metastasis.When diagnostic laparoscopy is combined with LUS, the diagnostic
accuracy of the procedure increases by 12-14%; however, few surgeons and centres have the skills and
equipment to interpret LUS images. Peritoneal lavage cytology can further improve the identification of
occult metastasis in 7-15% of patients; however, time constraints may hinder identification, and expert
cytopathologists may not be available.

The main controversy regarding SL is whether it should be used routinely or selectively in patients with
pancreaticadenocarcinoma deemed resectable on preoperative imaging. Proponents for the routine use of
SL cite the highincidence of imaging occult metastatic disease found during laparoscopic examination of the
abdominal cavity thatleads to avoidance of unnecessary operations and thus benefits patients. Proponents
for the selective use ofSL argue that when high quality imaging is used, only a small percentage of patients
benefit from SL, and underthese circumstances the procedure is not cost-effective.

256
Recommendations
Staging laparoscopy can be performed safely in patients with pancreatic adenocarcinoma
(grade B).
The procedureshould be considered after high quality imaging studies have excluded
metastatic disease in appropriately selectedpatients with either localized or locally
advanced pancreatic adenocarcinoma (grade C).
The use of laparoscopicultrasound and peritoneal washings is encouraged, since they
may improve the diagnostic accuracy of theprocedure (grade C).
Based on the available evidence, selective rather than routine use of the procedure may
bebetter justified and more cost-effective (grade C).

Gastric cancer
There is improved survival among gastric cancer patients with tumors (T3-T4N1) who received neoadjuvant
chemotherapy prior to definitive surgical resection. Studies indicated that gastric cancer patients with locally
advanced tumor or with lymph node metastases derived survival benefit; however, in the presence of
unresectable disease or disseminated metastases, 5-year survival remains poor (<20%). It is thus imperative
to identify gastric cancer patients who may benefit from neoadjuvant chemotherapy and those with
advanced or metastatic tumors who are not candidates for therapeutic laparotomy.

Staging laparoscopy can identify unsuspected metastatic disease in 13-57% of patients despite
negative preoperative imaging studies. Accuracy has been reported to range from 89-100% in different
series. In addition, exploratory laparotomy has been avoided in 17-40% of cases. Compared with CT
scan and ultrasound, SL is more sensitive (90-96%) for detecting hepatic metastasis compared with
both CT (28-52%) and ultrasound (23-37%). Similarly, sensitivity is also better for detecting peritoneal
metastasis (laparoscopy 69%, ultrasound 23%, CT 8%). The additional value of laparoscopic ultrasound
has not yet been determined. Peritoneal washings positive for cancer cells have been demonstrated to
correlate with the extent of disease (T1/T2: 0%, T3/T4: 10%, and M+: 59%)

Recommendations
Staging laparoscopy can be performed safely in patients with gastric cancer (grade B).
The procedure should be considered for patients with T3 or T4 tumors who are thought to
have localized or locally advanced disease on high quality preoperative imaging (grade B).
In contrast, the procedure has a very low yield in patients with early stage disease (T1 or
T2) and should therefore be avoided in this patient population (grade B).

Esophageal cancer
The overall prognosis for patients with esophageal cancer is poor. Many patients with esophageal cancer
present at an advanced stage with lymph node or even distant metastases. Patients with advanced cancer
commonly undergo preoperative chemotherapy and radiation in an attempt to improve survival. However, as
with other GI malignancies, preoperative imaging may suggest resectable disease, though a significant
percentage (20-65%) of esophageal cancers are found to be unresectable at the time of exploration.Thus, the
value of precise staging is important to separate patients with an early stage tumor who are candidates for
immediate curative resection fromthose who need neoadjuvant therapy. Staging laparoscopy may aid in
more accurate staging of esophageal cancers to guide the most appropriate treatment and avoid non-
therapeutic laparotomy. In addition, laparoscopic feeding jejunostomy can be placed during SL when
neoadjuvant therapy is anticipated. When all preoperative imaging indicates no metastatic disease, SL with
or without laparoscopic ultrasound has a sensitivity of 71% in finding peritoneal metastases, 78% for nodal
metastases, and 86% for liver metastases. This compares with ultrasound sensitivities of 14%, 11%, 86%,
respectively, and CT scan sensitivities of 14%, 55%, 71%, respectively. The accuracy has been reported to be
75-80%. In the hands of a skilled thoracic surgeon, combined thoracoscopic and laparoscopic staging can be
performed over 70% of the time which has a sensitivity of 64%, specificity of 60%, and accuracy of 60%.

Recommendations
Staging laparoscopy can be performed safely in patients with esophageal cancer (grade
B). Patients who are considered to be candidates for curative resection (early stage
esophageal cancer with no evidence for distant or lymph node metastases on high quality
preoperative imaging) may benefit from SL (grade B).
Staging laparoscopy also provides the opportunity for enteral feeding tube placement
without the need for laparotomy. (grade C)

257
Primary liver tumors
Staging laparoscopy is indicated in patients with primary liver tumors when preoperative imaging
suggests likely resectable disease and an adequate hepatic reserve.
Although the incidence of peritoneal metastases is uncommon in these patients, diagnostic
laparoscopy combined with LUS permits assessment of the entire hepatic parenchyma and allows
identification of the size, location, and number of liver tumors as well as potential vascular
invasion.The identification of hepatic tumors using triphasic CT scan is less sensitive than
laparoscopic ultrasound in correlation studies and is highly dependent on tumor size: 0-1 cm (71%), 1-2
cm (84%), 2-3 cm (96%), and greater than 3 cm (100%). Laparoscopic ultrasound can detect 9.5% more
tumors than CT alone, most of which are less than 1 cm. Staging laparoscopy correctly identifies 63-
67% of patients with unresectable disease. The most common reasons that SL missed unresectable
disease were vascular invasion, lymph node metastases, and adjacent organ invasion. With the
combination of SL and laparoscopic ultrasound, 16-25% of patients may avoid open laparotomy.
Recommendations
Staging laparoscopy with laparoscopic ultrasound can be performed safely in patients
with primary hepatic tumors (grade B).
Patients with primary hepatic cancers that appear resectable on preoperative imaging may
benefit fromSL with laparoscopic ultrasound to evaluate extent, location, and size of
disease (grade C).
Biliary tract tumors
Biliary tract tumors can be divided into two main categories: gallbladder cancers and
cholangiocarcinomas. The two groups differ in their patterns of spread and in prognosis. Gallbladder
cancer tends grow more rapidly and has earlier dissemination which makes SL a more useful tool in
this setting. In contrast, cholangiocarcinomas tend to be more locally invasive, decreasing the yield of
SL. Preoperative imaging to determine resectability of biliary tractcancers often includes ultrasound,
CT scan, direct cholangiography (PTC or ERCP), and/or MRCP. These radiologic preoperative studies
are used to evaluate the extent of tumor within the biliary tree, vascular invasion, hepatic lobar atrophy,
and metastatic disease.The increased availability of EUS may limit the yield of diagnostic laparoscopy
to those with T2 or T3 cholangiocarcinoma; most patients with T1 cancers are resectable.Staging
laparoscopy can detect peritoneal or superficial liver metastases (23%), which are often not detected
by preoperative imaging. Diagnostic laparoscopy has diagnostic accuracies of 48-60% and 53-60% for
identifying unresectable disease in patients with gallbladder cancer and cholangiocarcinoma,
respectively. The yield of SL for gallbladder cancer is slightly higher than for cancers of the biliary tree
because of the higher incidence of peritoneal and liver metastases associated with gallbladder cancer.
The added benefit of laparoscopic ultrasound in improving the diagnostic yield of the procedure has
been inconsistent in the literature (0-41%).

Staging laparoscopy can be performed safely in patients with cancers of the biliary tract
and gallbladder (grade B).
Staging laparoscopy may be used for suspected gallbladder cancers& biliary tract cancers
that are believed to be resectable bypreoperative, high quality imaging studies (grade B).

Colorectal cancer
In the primary treatment of colorectal cancer, SL is seldom used since surgical resection and palliation
are typically indicated to prevent bleeding, obstruction, and perforation even in patients with advanced
disease. However, patients who have liver metastases from a primary colorectal cancer may be
candidates for curative resection when there is no other extrahepatic disease, and when all of the
disease in the liver is resectable. Thus, SL for these patients can provide more accurate identification
of all hepatic lesions, including size, number, and location, thannon-invasive imaging.SL and
laparoscopic ultrasound have better sensitivity than imaging studies inthe detection of nodal
metastases (94% laparoscopic ultrasound vs. 18% imaging preoperatively). The combination of SL and
laparoscopic ultrasound has been reported to detect unresectable disease in 25-42% of patients in
whom preoperative radiological testing showed potentially curable disease.
Recommendations
Staging laparoscopy can be performed safely in patients with hepatic metastasis of
colorectal cancer (grade B).
Patients who are candidates for liver resection for isolated colorectal hepatic metastases
may benefit from SL with laparoscopic ultrasound. (grade B).

258
Lymphoma
Hodgkin lymphoma, or Hodgkin disease, originates in one nodal region/group and spreads to
contiguous nodal regions in a typically stepwise manner. The prognosis and treatment of Hodgkin
disease is determined based on the extent of the disease, involvement of extra nodal lymphatic sites,
and presence of constitutional symptoms. Hodgkin disease was typically staged by exploratory
laparotomy and biopsy of liver and enlarged lymph nodes followed by splenectomy; however, this
procedure is associated with significant morbidity.With improved radiologic imaging and image-guided
biopsy procedures, an open operation for staging lymphomas has become mostly obsolete.However, a
needle biopsy is associated with high false-negative rates, and architectural classification of
lymphomas cannot be interpreted from tissue obtained on a needle biopsy. The goals of the staging
workup for Hodgkin disease are to determine the presence of infradiaphragmatic disease and the
presence or absence of splenic and liver involvement. This information is especially relevant in
patients with clinical stage I and II Hodgkin disease, in that 25-40% of these patients will be upstaged
as a result of this information. The steps of SL are similar to the traditional open procedure:
Inspection for gross abnormalities
Core liver biopsy of each hepatic lobe and wedge biopsy of left lateral liver segment
Laparoscopic ultrasound to search for hepatic lesions
Splenectomy with removal of organ intact
Lymph node sampling of the following areas: iliac, celiac, portal, mesenteric, and peri-aortic
Lymph node excision of abnormal nodes identified on preoperative testing with application of
clips at those excision areas
Oophoropexy posterior to the uterus (to protect it from radiation injury)
Laparoscopy may also have a role in assessing treatment response or when a recurrence is
suspected.Diagnostic laparoscopy in patients with Hodgkin disease and NHL provides tissue for
diagnosis, aids in accurate staging, and prevents the morbidity of unnecessary laparotomy. Compared
with percutaneous biopsy, laparoscopy biopsy has superior sensitivity (87% vs 100%), specificity (93%
vs 100%), and accuracy (33% vs 83%).In contrast, for non-Hodgkin lymphoma, the exact extent of the
disease has less impact on the treatment course, and therefore, SL in non-Hodgkin lymphoma is less
frequently performed. The primary indication for SL in non-Hodgkin lymphoma is for tissue diagnosis
through biopsy of intra-abdominal lymph nodes in the absence of peripheral lymphadenopathy.

Staging laparoscopy in lymphoproliferative disorders is safe and effective (grade B).

The best indication for SL inlymphoproliferative disorders may be for obtaining tissue
diagnosis for non-Hodgkin lymphoma when core needlebiopsy is non-diagnostic and for
primary staging or even restaging in Hodgkin’s lymphoma when accurate stagingaffects
decisions for appropriate treatment and prognosis or when splenectomy is required (grade C)

TECHNIQUE
After appropriate preoperative evaluation, diagnostic laparoscopy may beperformed under either general or
local anesthesia. General anesthesia is preferredfor most cases, especially if cancer staging is to be
performed. Diagnosticlaparoscopy may be performed in the operating room (most common) or ina treatment
area equipped for administration of anesthesia and with full resuscitativesupport. A proper table that allows
the patient to be placed in both fullTrendelenburg and reverse Trendelenburg positions during examination
is essential.Appropriate time should be taken for a full examination of the upper andlower abdomen. This
generally requires creating a pneumoperitoneum usingcarbon dioxide at 10 to 12mmHg.A 5 mm or 10-mm
laparoscopeis preferred utilizing both 0-degree and 30-degree cameras for full visualization. Place the
laparoscope through a midlinesubumbilical trocar site using a 10/11-mm trocar sleeve. Depending on the
areato be examined, place one or two additional 5-mm trocars in respective quadrant.These will be used for
grasping forceps, palpating probes, and biopsy forceps.
Specific areas of biopsy depend on the nature of the lesion and the tumor undergoing staging. For
example, in patients with lower esophageal and gastric cancer, the liver must be closely inspected and
biopsies should be performed on any lesions on the surface of the liver. In addition, the gastrohepatic
and gastrocolic omental areas may be divided to allow for evaluation of nodal tissue in these areas.
Lymph nodes should be removed intact, if possible, to achieve better histologic identification. In
assessing the patient with pancreatic cancer, the duodenum may be mobilized by means of Kocher
maneuver. Biopsies may be performed on retroduodenal tissue and lymph nodes may be assessed as
follows. The gastrocolic omentum should be divided and the superior pancreatic area should be to
observe for evidence of local or regional pancreatic cancer.

259
In addition, lavage with 500 mL of saline should routinely be performed to obtain fluid for
cytologic investigation. The operating table should be angled into various positions to allow for
the disbursement of the lavage fluid.
Techniques utilized during diagnostic or staging laparoscopy (Malignant
conditions) • Full abdominal and pelvic evaluation
A thorough evaluation of peritoneal surfaces is performed. The suprahepatic and infrahepatic spaces, the
surface of the bowel, the lesser sac, the root of the transverse mesocolon and small bowel, the ligament of
Treitz, the paracolic gutters, and pelvis are inspected with frequent bed position changes as necessary.
Division of gastrohepatic omentum
Biopsy using cupped forceps or core needle
Abdominal lavage for cytologic study
Retrieval of ascitic fluid for cytology and culture
Identification and removal of enlarged lymph nodes
Laparoscopic ultrasound
Techniques utilized during diagnostic laparoscopy (Acute, Chronic, and Trauma)
The peritoneal cavity can be examined systematically taking advantage of patient
positioning manipulations.
In penetrating injuries, peritoneal violation can be determined.
Appendix visualization in RIF by following tenia of the cecum
Visualization of small bowel from Ligament of Treitz to ileo cecal
junction Examination of large bowel
Pelvis and adnexal structure evaluation (Trendelenburg
position) Hernial orifices should be inspected.
Diaphragm assessment for sure.
Supracolic compartment- liver, GB, duodenum, stomach (Pancreas)
Methylene blue can be administered IV or via a nasogastric tube to help identify urologic
or stomach injuries, respectively.

Laparoscopic ultrasonography is a relative latecomer to the area of surgical sonography whose

arrival can be attributed to the need for development of specialized transducers that could fit
through conventional laparoscopic trocars. Standard diagnostic laparoscopy is a two-dimensional
modality that permits excellent visualization of the peritoneal structures. However, it is limited by
the lack of tactile sensation. The inability to see the undersurface of the organs can limit the utility
of laparoscopic staging. Direct palpation of the liver with blunt laparoscopic instruments may be
useful. However, identification of small tumors or a precise delineation of the anatomic relation of
a tumor to adjacent structures is often difficult or not possible.
Laparoscopic ultrasonography (LUS) is an excellent adjunct to traditional laparoscopy and can be rapidly
performed. LUS probes (curved- or linear-array technology) with high frequency performance (5-10 MHz) with
depth of penetration of approximately 4-10 cm, permit high-resolution images to be obtained and can detect
lesions as small as 0.2 cm within the hepatic parenchyma.Color Doppler assessment can also be performed
to allow accurate identification of blood vessels. Though primarily used for assessment of the hepatic
parenchyma, LUS has been used extensively for evaluation of the biliary tract and in the staging of upper GI
malignancies, by allowing assessment of liver metastases, regional nodal disease, or local vascular
involvement. A number of authors have suggested that LUS provides additional information in only 14-25%
of patients during staging procedures, but some authors believe that the yield is much less.

LUS for the staging of gastric cancer patients can be performed safely, adds little time to the duration of
staging laparoscopy, and does not increase significantly patient morbidity (Grade A recommendation).
LUS for routine use in pretherapeutic staging of esophageal cancer is limited. Nevertheless, DL
with ultrasound should be considered in patients with esophagogastric malignancies who do
not have metastatic disease on high quality staging CT scan (Grade C).
LUS is useful for staging of hepatocellular and metastatic colon and rectal cancers and
can help guide treatment or avoid unnecessary open operations (Grade B) and detect
metastasis from other cancers (Grade C).
LUS can be performed safely in patients with pancreatic adenocarcinoma and other
pancreatic diseases (Grade B).
LUS provides additional prognostic information to DL in a fraction of examined patients
with pancreatic adenocarcinoma and further decreases the rate of unnecessary
laparotomies (Grade C).

260
COMPLICATIONS
Inherent to all laparoscopic procedures like those related to anesthesia and those associated with
creation of the pneumoperitoneum/insertion of the trocars and may include the following:
Anesthesia-related complications
Extra-peritoneal gas insufflation
Injury to intra-abdominal
structures Bladder injury
Pneumothorax/pneumomediastinum
Gas embolism
Bowel injury
Port-site recurrence

Port-site recurrence
Although laparoscopic staging of intra-abdominal cancers is a safe technique associated with a low (1-
2%) rate of major morbidity (eg, hemorrhage, visceral perforation, or intra-abdominal infection), there
was an initial concern of higher rates of port-site recurrence following staging laparoscopy. Dobronte
et al first reported a case of port-site tumor recurrence 2 weeks after laparoscopy in a patient with
malignant ascites. Thereafter, multiple authors have expressed concern regarding the potential risk of
disseminating disease at the time of pneumoperitoneum.A number of hypotheses have been suggested
to explain port-site implantation, including tumor seeding associated with carbon dioxide
pneumoperitoneum in animal studies, tissue manipulation, direct wound contamination, poor surgical
technique, or immunologic effects such as changes in host immune responses. However, with
improved expertise and use of an impervious barrier bag for organ retrieval, there has been no
documentation of increased port-site recurrence following staging laparoscopy as compared with open
exploration.Pearlstone et al, based at MD Anderson Cancer Center, reported results of diagnostic
laparoscopy in 533 patients with intra-abdominal cancer (nongynecologic), of whom 339 had upper GI
malignancies. The authors reported port-site recurrences in four patients (0.88%), three of whom had
advanced disease at the time of initial laparoscopy. A similar study from Memorial Sloan-Kettering
Cancer Center reported on 1650 diagnostic laparoscopic procedures performed among 1548 patients
with upper GI malignancies, in whom a total of 4299 trocars were inserted. After a median follow-up of
18 months, port-site recurrence was noted in 13 patients (0.8%). An open operation was performed in
1040 patients, of whom nine (0.9%) developed a wound recurrence.This latter figure is similar to the
0.8-1% incisional recurrence rate noted in open laparotomies for cancer. The authors concluded that
laparoscopic staging appeared safe from an oncologic standpoint because port-site implantation is
uncommon, differs little from open surgical incision recurrence, and likely reflects the underlying
biologic behavior of the disease rather than the type of surgery.
“Different diagnostic modalities to evaluate the abdomen”
Investigations Advantages Disadvantages
Diagnostic peritoneal lavage Inexpensive Invasive
Easy to perform Nonspecific
Expeditious Cannot identify type of injury
Transportable Cannot identify severity of injury
Few complications Not reliable for diaphragm or
Sensitivity >95% retroperitoneal injuries
Determines character of fluid High false-positive rate
High nontherapeutic laparotomy
rate
Computed Tomography Non-invasive Expensive
Localizes site of injury Need skilled technician
Best for solid organ injuries Time consuming
Best for retroperitoneal Availability May miss bowel injuries
injuries
Availability
Ultrasonography Noninvasive Less sensitive than CT
Easy to perform Large learning curve
Expeditious Availability
Transportable May miss bowel injuries
Unreliable in obese patients
Cannot localize injury

261
Diagnostic Laparoscopy Accurately localizes injury Expensive

Demonstrates active bleeding Invasive

Localizes source of bleeding
Best for diaphragm injuries
Can be therapeutic
Decreases nontherapeutic
laparotomies (about 25%)
Difficult to quantify blood volume
Time consuming
May miss retroperitoneal injuries
May need anesthesia
Gas embolism
Tension pneumothorax if
diaphragm injury present
Difficult to quantify blood volume

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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 GastrointSurg 2005;9:476-80.
Goletti O, Celon G, Galatioto C, et al. Is laparoscopic sonography a reliable and sensitive procedure for staging
colorectal cancer? Surg Endosc 1998;12:1236-41.
Walsh RM, Heniford BT. Role of laparoscopy for Hodgkin's and non-Hodgkin's lymphoma. Semin Surg Oncol. 1999
Jun. 16(4):284-92.
Lefor AT. Laparoscopic interventions in lymphoma management. Semin Laparosc Surg. 2000 Jun. 7(2):129-39.
Kim HJ, D'Angelica M, Hiotis SP, Shoup M, Weber SM. Laparoscopic staging for liver, biliary, pancreas, and gastric
cancer. Curr Probl Surg. 2007 Apr. 44(4):228-69.
Dobronte Z, Wittmann T, Karacsony G. Rapid development of malignant metastases in the abdominal wall after
laparoscopy. Endoscopy. 1978 May. 10(2):127-30.
Pearlstone DB, Mansfield PF, Curley SA, Kumparatana M, Cook P, Feig BW. Laparoscopy in 533 patients with
abdominal malignancy. Surgery. 1999 Jan. 125(1):67-72.
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 Aug. 9(7):632-6.
Amarapurkar D, Bhatt N, Patel N, Amarapurkar P, Amarapurkar A. Diagnostic laparoscopy in the era of modern
imaging-- retrospective analysis from a single center. Indian J Gastroenterol. 2013 Sep;32(5):302-6.
Hajibandeh S, Hajibandeh S, Gumber AO, Wong CS. Laparoscopy versus Laparotomy for the management of penetrating
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Li Y, Xiang Y, Wu N, Wu L, Yu Z, Zhang M, Wang M et al. A Comparison of Laparoscopy and Laparotomy for the Management
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surgery and trauma. World J Gastroenterol. 2016 Jan 14;22(2):668-80

COMPONENTS SEPARATION (CST) IN MIDLINE VENTRAL HERNIA

-Dr. Romesh Lal,

INTRODUCTION:
Functions of abdominal wall include protection of the abdominal organs, maintenance of upright posture and
support the spine, assist bodily functions requiring generation of Valsalva maneuver like coughing, urination
or defecation and provide aesthetic body image. Also, absence of an intact abdominal wall results in loss of
the mechanical endpoint of satiety leading to unintentional weight gain.

MANAGEMENT OPTIONS FOR VENTRAL HERNIA REPAIR (MVH):

Include simple tissue repair, prosthetics & bio-prosthetics, components separation technique
(CST) or “Separation of parts” and combined CST with prosthetics. Other options are tissue
expansion, flaps and vacuum-assisted closure therapy.
COMPARISON OF RECURRENCE RATES (RR) & SSE:
Simple tissue repair has (RR of > 50% & SSE of 2+), Pure CST (22% & 3+), Open mesh repair (11%
& 3+), Lap bridging mesh repair (1-5% & 2+), Open CST with mesh reinforcement (1-5% & 3+) and
Endoscopic CST with IPOM (0-4% & 1+).

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PREOPERATIVE FACTORS AFFECTING CHOICE OF PROCEDURE:
Include defect size, location, patient comorbidities, presence of contamination, acuity of the patient’s
presentation, necessity for an ostomy and history of prior repairs with or without a prosthetic.
POSTOPERATIVE FACTORS: VHWG CLASSIFICATION OF SURGICAL SITE EVENTS (SSE):
Includes infection, sterile fluid collections like seroma and hematoma, wound dehiscence, entero-
cutaneous fistulas and recurrence.
INTRA-ABDOMINAL PRESSURE (IAP):
It is an important consideration in the management of MVH as forceful closure of the ventral
hernia might lead to increased IAP. IAP ˃ 20 mm Hg constitutes intra-abdominal hypertension
(IAH). Abdominal compartment syndrome (ACS) manifests if IAP ˃ 25 mmHg. It is a condition
requiring emergent abdominal decompression.
Yardsticks of Success of a Procedure:
Traditional: Post operative morbidity and recurrence rate
Current:Functional outcome, cosmetic outcome and quality of life

COMPONENTS SEPARATION TECHNIQUE (CST)

Principle of CST:Unilateral or bilateral release of one of the three muscles of the abdominal wall
through a long relaxing incision. This leads to weakening of traction on the remaining wall thereby
firstly helps to slide & advance the remaining vascularized, innervated musculofacial layers of
abdomen medially facilitating midline closure and secondly increases the total abdominal
capacity thereby compensate for the domain loss in very large ventral hernias.
Midline Closure of Defect: Is the ESSENCE of CST:Because intact midline provides anchorage for
the lateral abdominal wall. Large midline defects can be closed with “physiological” tension” to
create a new linea alba without use of prosthetic materials.
Advantages: Neo linea alba helps restore anatomy and dynamic integrity resulting in improved
abdominal wall function and improved contour due to reduced “pseudo-recurrences” and better quality
of life (QOL). Reduced seroma formation rate helps reduce morbidity and reduced recurrence rate.
Other benefits may include improved respiratory function, need for a smaller sized mesh helping to cut
down costs and facilitate concurrent additional surgery e.g. bariatric surgery.

Types of CST based on approach:

1. Open approach: a) Anterior CST: Release of external oblique aponeurosis
b) Posterior CST: Release of transverse abdominis aponeurosis (TAR)
2. Endoscopically assisted Ant. CST: Release of external oblique aponeurosis
3. Hybrid ( combination of open & lap) Release of external oblique aponeurosis

After CST further procedure: May include augmentation with Meshplasty

INDICATIONS FOR CST
Only CST:Large midline ventral hernias in the presence of infection, patients who are also having
a colostomy reversal and prophylaxis/treatment of abdominal compartment syndrome.
CST reinforced with Mesh: Large midline ventral hernia, midline hernia with multiple defects,
multiple failed repairs of incisional hernias and patients with loss of domain.

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ENDOSCOPIC CST WITH IPOM VERSUS OPEN CST WITH ONLAY OR SUBLAY MESH: Endoscopy:
Advantages of lap: Eliminates large surgical incisions, reduced wound complications, lower risk
of mesh contamination, less post-op pain, rapid recovery, early discharge, reduction in overall
costs, possibility in recurrent hernias & ostomies through rectus.
Endoscopy: Advantages of CST: Better able to assess entire abdominal wall, ensure proper mesh
overlap, morbidly obese, preserves blood supply to skin, decreases operative time, less blood
loss and in the elderly.
Endoscopy: Disadvantages:Steeper learning curve, medialization only 85% of open CST,
disfigured scars needing excision, multiple abdominal surgeries- “frozen abdomen”, difficult
when incisions extend lateral to linea semilunaris and development of lateral hernias.
OPEN COMPONENT SEPARATION TECHNIQUES
Ramirez’s Classical Anterior CST (1990):
Dissection of overlying skin & subcutaneous tissue from anterior rectus sheath & EOM.
Cutting EO aponeurosis from costal margin to inguinal ligament. Separation of EOM from
IOM laterally to allow sliding and translation. Advancement of musculoaponeurotic bundle
medially and approximating it to the opposite side to create “neo line alba” in the midline.
Upto 20 cm defect could be closed. Incision of posterior rectus sheath and freeing of the
rectus muscle can add a few more cms to this. However, associated with high morbidity
including hematoma, seroma, infection & skin necrosis.

Saulis & Dumanian -Periumbilical rectus abdominis perforator preservation (2002):

Proposed that preserving the periumbilical rectus abdominis perforators to the abdominal skin
flaps will decrease the prevalence of postoperative superficial wound complications. Noted a
reduction in wound ischemia and skin necrosis. No reduction in hematoma & seroma.

Rives-Stoppa-Wantz- Posterior CST (Retro-Rectus Repair) (1989):

Opening of the anterior rectus sheath bilaterally to redevelop the posterior facial wall.
Reconstruction of the facial wall and insertion of the prosthetics behind the rectus muscle
plane in partial contact with the subcutaneous tissue.

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 2012: Novitsky- Open posterior CST –Transverse abdominis release (TAR) (2 012):
This novel technique of trans versus abdominis muscle release (TAR) for posterior component
separation during major abdom inal wall reconstructions is a modification of the classic
retromuscular Stoppa technique to facilitate d issection beyond the lateral border of the rectus s
heath. Briefly, the retromuscular space is developed laterally to the edge of the rectus sheath. Th e
posterior rectus sheath is incised 0.5-1 cm unde rlying medial to the linea semilunaris to expose
the medial edge of the transversus abdominis muscle. The muscle then is divided, allowing
entrance to th e space anterior to the transversalis fascia. The posterior rectus fascia then is
advanced medially. The mesh is placed as a sublay and the linea alba is r estored ventral to the
mesh. It was associated with a low perioperative morbidity and a low recurrence rate.

ENDOSCOPIC ASSISTED CST

1. Lowe et. al. – Endoscopic CST (2000) & Maas et. al.- Endoscopic CST (2002):
Introduction of endoscope (laparoscope) in the anterior axillary line and creation of a
space between the subcutaneous tissue and EOM (Lowe) or between the EOM and IOM
(Maas), lateral to linea semilunaris with the help of hernia balloon spacemaker.
Cut the EO aponeurosis from above costal margin to inguinal ligament through this space
to carry out Anterior CST. Preserves blood supply to skin medially and prevents ischemia.

Rosen et.al.)- Combined E ndoscopic CST wit laparoscopic IPOM mesh re pair (2007):
Is a minimally invasive bila teral laparoscopic component separation. A 10-m m incision is made
lateral to the rectus abdom inus muscle. The external oblique fascia is incised , and a dissecting
balloon is inflated between the internal and external oblique muscles. Two additional ports are
placed in the intermuscular space. The external oblique is incised from the c stal margin to the
inguinal ligament. The max imal abdominal wall advancement achieved is an average of 86% of the
myofascial advancement compared with a formal open release. The laparoscopic approach does not
require extensive subcutaneous dissection and might theoretically re ult in a decreased incidence or
decreased co mplexity of postoperative wound infections or skin-fla p necrosis.

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CONCLUSION
Large complex midline ventral hernias are a surgical challenge.
Components separation with or without a prosthetic reinforcement is an excellent option in
these large midline ventral hernias
It facilitates midline closure and creation of a neo linea alba.
This helps to improve dynamic function of the abdominal wall and also has better cosmetic
outcome.
Endoscopic CST is associated with a significant reduction in the post operative morbidity an
overall improvement in the quality of life.

NECK DISSECTION
- Dr. Pankaj Kumar Garg, Manish Kumar Gaur

The terms neck dissection and cervical lymphadenectomy are synonymous, and both refer to the
systematic removal of lymph nodes, along with their surrounding fibrofatty tissue, from the
various compartments of the neck. This procedure is used to eradicate the metastases to the
regional lymph nodes of the neck.
Metastasis to the regional lymph nodes reduces the 5-year survival rate by almost 50% compared with
that of patients with early stage disease. Neck node metastasis is the most important prognostic factor
in head and neck cancers. In most patients, these metastases originate from primary lesions that
involve mucosal sites of the upper aerodigestive tract, particularly the oral cavity, pharynx, and larynx;
cutaneous malignancies of the face and scalp and cancers that arise in the nose and sinuses, as well
as salivary and thyroid glands, are also sources of metastatic nodal spread.
Certain subsites—such as the oral tongue, floor of the mouth, piriform sinus, and supraglottic larynx—
are associated with higher rates of lymphatic metastasis compared with such subsites as the buccal
mucosa, lip, nasal cavity, paranasal sinuses, and glottic larynx. When neck dissection is performed for
palpable or radiologically detectable metastatic disease in a patient with previously untreated cancer, it
is referred to as a therapeutic neck dissection. Frequently, a neck dissection may be electively
performed, called prophylactic neck dissection even in the absence of clinical or radiologic evidence of
disease; this is done when the likelihood of microscopic lymphatic metastasis is significantly high.
Historic Perspective
The first conceptual approach for removing nodal metastases was made in 1880 by Kocher, who
described the removal of the lymph nodes located within the contents of the submandibular
triangle to gain surgical access to a cancer of the tongue. The first description of the radical neck
dissection (RND) was by Jawdynski, a Polish surgeon. However, the individual credited the most
for developing and reporting the efficacy of this procedure is Crile, who believed that distant
(hematogeneous) metastases were uncommon in head and neck cancer and that metastases more
commonly occurred in the neck through the permeation of lymphatics.
Blair, Brown and Martin, who were strong proponents of the radical en bloc technique of neck
dissection in a manner similar to the radical surgery that had evolved for breast cancer. Martin in
particular categorically insisted that the spinal accessory nerve, the IJV, and the SCM should be
removed as part of all cervical lymphadenectomies.
In the 1950s, Ward and Robben reported that the neck dissection could be modified in some
circumstances by sparing the spinal accessory nerve and thereby preventing postoperative
shoulder drop.
The concept of conservation neck surgery was further popularized during the 1960s by Suarez in
Argentina and was promoted by Bocca and Pignataro who independently described an operation that
removed all of the lymph node groups while sparing the spinal accessory nerve, SCM, and IJV.

ANATOMY OF THE CERVICAL LYMPHATICS

The nodal groups at risk for involvement are widespread throughout the neck and extend from the
mandible and skull base superiorly to the clavicle inferiorly and from the posterior triangle of the
neck laterally to the midline viscera and to the contralateral side of the neck. It is now
recommended that the lymph node groups in the neck be categorized according to the level
system originally described by the Memorial Sloan-Kettering Group in 1930s.

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 Table 1. Lymph Node Groups Found within the Six Neck Levels and the Six Sublevels
Lymph Node Description
Group
Submental (sublevel Lymph nodes within the triangular boundary of the anterior belly of the digastric muscles and
IA) the hyoid bone
Submandibular Lymph nodes within the boundaries of the anterior belly of the digastric muscle, the stylohyoid
(sublevel IB) muscle, and the body of the mandible, including the preglandular and postglandular nodes
and the prevascular and postvascular nodes.
Upper jugular Lymph nodes located around the upper third of the internal jugular vein and the adjacent
(sublevels IIA and spinal accessory nerve, extending from the level of the skull base above to the level of the
IIB) inferior border of the hyoid bone below. Sublevel IIA nodes are located anterior (medial) to the
vertical plane defined by the spinal accessory nerve. Sublevel IIB nodes are located posterior
(lateral) to the vertical plane defined by the spinal accessory nerve.
Middle jugular (level Lymph nodes located around the middle third of the internal jugular vein, extending from the
III) inferior border of the hyoid bone above to the inferior border of the cricoid cartilage below. The
anterior (medial) boundary is the lateral border of the sternohyoid muscle, and the posterior
(lateral) boundary is the posterior border of the sternocleidomastoid muscle.
Lower jugular (level Lymph nodes located around the lower third of the internal jugular vein, extending from the
IV) inferior border of the cricoid cartilage above to the clavicle below. The anterior (medial)
boundary is the lateral border of the sternohyoid muscle, and the posterior (lateral) boundary
is the posterior border of the sternocleidomastoid muscle.
Posterior triangle This group is composed predominantly of the lymph nodes located along the lower half of the
(sublevels VA and spinal accessory nerve and the transverse cervical artery. The supraclavicular nodes are also
VB) included in the posterior triangle group. The superior boundary is the apex formed by the
convergence of the sternocleidomastoid and trapezius muscles; the inferior boundary is the
clavicle, the anterior (medial) boundary is the posterior border of the sternocleidomastoid
muscle, and the posterior (lateral) boundary is the anterior border of the trapezius muscle.
Sublevel VA is separated from sublevel VB by a horizontal plane marking the inferior border of
the anterior cricoid arch. Thus sublevel VA includes the spinal accessory nodes, whereas
sublevel VB includes the nodes that follow the transverse cervical vessels and the
supraclavicular nodes (with the exception of Virchow’s node, which is located in level IV).
Anterior Lymph nodes in this compartment include the pretracheal and paratracheal nodes, the
compartment (level precricoid (Delphian) node, and the perithyroidal nodes, including the lymph nodes along the
VI) recurrent laryngeal nerves. The superior boundary is the hyoid bone, the inferior boundary is
the suprasternal notch, and the lateral boundaries are the common carotid arteries.
Superior These nodes represent an extension of the paratracheal lymph nodes chain extending
mediastinum inferiorly below the suprasternal notch along each side of the cervical trachea to the level of
(optional—level VII) the innominate artery.

Figure 1. The six sublevels of the neck for describing the location of lymph nodes within levels I,
II, and V. IA, submental group; IB, submandibular group; IIA, upper jugular nodes along the
carotid sheath including the subdigastric group; IIB, upper jugular nodes in the submuscular
recess; VA, spinal accessory nodes; and VB, the supraclavicular and transverse cervical nodes.

Neck Dissection Classification

The classification for neck dissection recommended by the AHNS is based on the following rationale:
that RND is the standard basic procedure for cervical lymphadenectomy, and all other
procedures represent one or more modifications of this procedure.
when modification of the RND involves the preservation of one or more non-lymphatic
structures, the procedure is called a modified radical neck dissection.

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 when the modification involves the preservation of one or more lymph node groups that
are routinely removed in the RND, the procedure is called a selective neck dissection
When the modification involves the removal of additional lymph node groups or nonlymphatic
structures relative to the RND, the procedure is called an extended radical neck dissection.
Procedures that dissect all five levels (RND and MRND) are also commonly referred to as
‘comprehensive neck dissections’.
This classification has been updated by the AHNS classification and is outlined in table 2.
Table 2. American Head and Neck Society Classification of Neck Dissection
Terminology Definition
Radical Removal of lymph node levels I to V, sternocleidomastoid muscle, spinal accessory
nerve, and internal jugular vein
Modified Removal of lymph node levels I to V, as in RND, but with preservation of at least one
of the nonlymphatic structures (sternocleidomastoid muscle, spinal accessory nerve,
internal jugular vein)
Selective Preservation of one or more lymph node levels relative to an RND
Extended Removal of an additional lymph node level or group or a nonlymphatic structure
relative to an RND (muscle, blood vessel, nerve); examples of other lymph node
groups are superior mediastinal, parapharyngeal, retropharyngeal, periparotid,
postauricular, suboccipital, or buccinators; an example of other nonlymphatic
structures can be external carotid artery or hypoglossal or vagus nerves

A planned neck dissection is typically performed 6 to 8 weeks after the completion of RT or CRT
when the probability of residual disease in the neck is high. As opposed to a planned neck
dissection, a salvage neck dissection is performed when metastatic disease in the neck occurs
after it has been previously treated. The salvage neck dissection can be further classified as an
early procedure, when it is done for persistent disease after chemotherapy or radiation or a
combination of both, or late, when it is done for recurrent disease.
Radical Neck Dissection
Definition: This procedure includes the removal of all ipsilateral cervical lymph node groups that
extend from the body of the mandible superiorly to the clavicle inferiorly and from the contralateral
anterior belly of the digastric muscle and the lateral border of strap muscles anteriorly to the anterior
border of the trapezius muscle posteriorly. It does not include the removal of the postauricular and
suboccipital nodes, periparotid nodes (except for a few nodes located in the tail of the parotid gland),
perifacial and buccinator nodes, retropharyngeal nodes, and paratracheal nodes.
Indications :
Significant operable neck disease (N2a, N2b, N3) with tumour bulk near to or directly
involving spinal accessory nerve and/or internal jugular vein
Extensive recurrent disease after previous selective surgery or
radiotherapy Clinical signs of gross extranodal disease

Untreatable primary tumour or unresectable neck disease (i.e. encasement of internal

carotid artery, brachial plexus, prevertebral fascia)
Patient unfit for major
surgery Distant metastases
Simultaneous bilateral neck dissection (preserve one internal jugular vein)

Definition: A modified radical neck dissection is defined as the en bloc removal of lymph node–
bearing tissue from one side of the neck (levels I through V). Unlike the RND, one or more of the
following structures is preserved in the modified radical dissection: the spinal accessory nerve,
IJV, and/or SCM. The major purpose of these modifications relates to the morbidity encountered
when the spinal accessory nerve is removed.

Ability to remove grossly visible lymph node disease that is not directly infiltrating or fixed to the
non-lymphatic structures, particularly if several levels are
involved Selective Neck Dissection
Definition: The procedure consists of the en bloc removal of one or more lymph node groups at risk for
harboring metastatic cancer, an assessment that is based on the location of the primary tumor. Thus
the levels removed depend on the location of the primary lesion and its known pattern of spread.

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Indications:
SND is performed for patie nts who are at risk for early lymph node
metastases. Figure 2 displays the various types of Selective neck dissection

Figure 2. Various types of Selective neck dissection

SELECTIVE NECK DISSECTION F OR ORAL CANCER

For oral cavity cancer, the procedure of choice is SND (levels I through III), and this is
often called supraomohyoid n eck dissection.
It is also indicated for t he contralateral neck in midline lesions of the floor of mouth or
ventral tongue.
Other indications inclu de extension of parotid surgery in cases of malignancy or facial
skin malignancies in a line a nterior to the tragus.
The SND (I–IV) often called extendedsupraomohyoid neck dissection is indicated for oral cancer
of the anterolat eral part of the tongue in which lymph node level IV is also considered
to be at risk.
SELECTIVE NECK DISSECTION F OR OROPHARYNGEAL, HYPOPHARYNGEAL A ND
LARYNGEAL CANCER
The SND (II–IV) oft en called lateral neck dissection is indicated in oropharyngeal,
hypopharyngeal and lar yngeal tumours in which levels II–IV are the most a risk
SELECTIVE NECK DISSECTION F OR METASTASES OF CUTANEOUS CANCER
SND (II-V, postauricula r and suboccipital/posterolateral dissection) is do ne for lymph
node metastases of skin tumours of the scalp and neck (posterior to the tragus)

In addition to the various medical co mplications that may occur after any surgical procedure in
the head and neck region, a number of surgi cal complications may be related solely or in part to
the neck dissection. When a neck dissection is done after RT of more than 70 Gy, the risk of com
plications may be higher.
Nerve Injury
Greater auricular nerve (GAN) - It has two divisions which innervate the pinna and
the skin posterior to it and trauma to this sensory nerve numbs those ar eas. The
GAN lies lateral to the externnal jugular vein. Both these structures are
subcutaneous, do not have protection of the pl atysma and can be easily damaged
in the process o f incising the skin. The posterior bran ch can be sacrificed during
parotidectomy after safely identifying and preserving the anterior branch.
Marginal mandibul ar nerve - The MMN which is the upper division o f the cervicofacial
trunk of the facial nerve exits the parotid fascia and traverses the s uperficial investing
fascia of the neck to innervate depressor anguli oris, the depressor labii inferioris, the
inferior fibers of the orbicularis oris and the mentalis muscles.

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 Damage to this nerve can cause salivary incontinence and esthetic impairment due
to an alteration in the balance of the musculature around the lower lip, preventing
lateral and downwards movements and lower lip inversion. MMN can be identified
at the point where it exits from the parotid by dissecting the fascia 1 cm below and
lateral to the angle of mandible. The nerve runs in the fascia over the facial
vessels. After dividing the facial vessels they can be retracted upwards moving the
nerve out of the path of further neck dissection.
c. Spinal accessory nerve - Spinal accessory is a motor nerve supplying the
sternocleidomastoid and the trapezius muscles. During neck dissection, it can be identified
either at its exit from the jugular foramen where it runs lateral to the internal jugular nerve or
at the Erb’s point where it can be located 1 cm posterior and superiorly. Approximately 30%
of patients will suffer from a shoulder dysfunction following handling of the SAN during
level II and V dissection. Early postoperative shoulder physiotherapy including both active
and passive movements along with progressive resistance exercise training (PRET) is found
to be more effective than routine physiotherapy. Patients with advanced shoulder
dysfunction cannot be offered much relief due to physical changes such as muscular
atrophy, capsular adhesions and fibrosis. Hence it is imperative to initiate shoulder
exercises in all patients following a neck dissection.
Haemorrhage
Intraoperative and reactionary haemorrhage - It can be anticipated during neck
dissection from vessels in close proximity to lymph node groups. The most common
veins injured are the tributaries of the internal jugular vein which usually arise from
structures medial to the IJV, those coming from the thyroid gland (middle thyroid vein),
the pharyngeal veins alongside the hypoglossal nerve and the facial vein. The various
arteries encountered during neck dissection are the occipital artery at Level II, the
superior thyroid artery at Level III and the transverse cervical vessels at Level IV and V
lymph nodes. Special attention needs to be focused on these named and other small
unnamed vessels during surgery to avoid immediate haemorrhage on reversal of
anesthesia when the intra-thoracic pressure varies.
Reactionary haemorrhage usually manifests by swelling of the wound site. An expanding
hematoma needs to be explored in operating room and requires control of the site of the
bleeding. Stable hematomas can be aspirated with application of the pressure dressing,
while organized non-fluctuant haematoma can be managed conservatively.
Secondary hemorrhage – It is less predictable in terms of onset and severity. It
commonly occurs 5-10 days after surgery and the cause is usually attributed to
infection, producing breakdown of clot leading to bleeding. It may be unheralded
and unexpected resultin in late presentation. In these situations, the wound is
explored and proximal vascular is required to control the hemorrhage.
Chylous leak- Despite the surgeon’s best efforts to avoid it, a postoperative chylous fistula occurs
after 1% to 2% of neck dissections. To prevent the chylous fistula, as soon as the dissection of
area around thoracic duct is completed, and again before closing the wound, the area should
be observed for 20 or 30 seconds while the anesthesiologist increases the intrathoracic
pressure (Valsalva maneuver); even the smallest leak of chyle should be pursued until it is
completely controlled. Management of this complication depends on the time of onset of the
leak, the amount of chyle drainage in a 24-hour period, and the physician’s ability to prevent
accumulation of chyle under the skin flaps. When the daily output of chyle exceeds 600 mL,
especially when the chyle fistula becomes apparent immediately after surgery, conservative
closed-wound management is not likely to succeed. In such patients, early surgical exploration
is preferred, before the tissues exposed to the chyle become markedly inflamed and before the
fibrinous material that coats these tissues becomes adherent, thus obscuring and jeopardizing
important structures, such as the phrenic and vagus nerves. Chylous fistulae that become
apparent only after enteral feedings are resumed, and particularly those that drain less than
600 mL of chyle per day, are initially managed conservatively with closed-wound drainage,
pressure dressings, and low-fat nutritional support.
Skin Flap necrosis – Skin flap necrosis can be catastrophic in the performance of of a radical
neck dissection because it can lead to exposed vital structures, primalrily the carotid
artery. The carotid artery, particularly whne previously irradiated, does not tolerate
exposure and must e covered early.

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 Avoidance of skin fklap loss is significamtly easier than management of the complication
once it has developed. Prevention includes the selection of appropriate incisions to avoid
long, narrow, poorly vasculatrized flaps.
Facial/cerebral edema- Synchronous bilateral RNDs, in which both IJVs are ligated, may result in
the development of facial and/or cerebral edema. Facial edema appears to be more common
and more severe in patients who have had previous irradiation to the head and neck. Massive
facial edema may be prevented by preserving at least one external jugular vein whenever a
bilateral RND is anticipated. Ligation of the IJVs leads to increased intracranial pressure.
Pneumothorax - Too much lower neck dissection may cause injury to the apical pleura causing
pneumothorax. Patient may become restless, cyanosed and dyspnoeic after operation. A plain
radiograph of chest most often provides the diagnosis. Minimal emphysema may resolve itself
but whereas severe cases may require intercostal chest drains.
Painful shoulder syndrome – Shoulder pain is a common squeal of neck dissection particularly
in those procedures in which the accessory nerve is sacrificed. Loss of trapezius support
allows he shoulder to drop resulting in decreased shoulder mobility and pain. This lends
secondarily to fibrosis and further disability. Early physical therapy is key to the prevention of
this complication. Patient should be instructed to continue this therapy after discharge.
Key Points to remember
Neck dissection is an operative procedure designed to remove metastases that involve the
regional cervical lymph nodes.
The gold standard procedure is RND, which for most patients is too extensive and results
in excessive morbidity.
Modifications of the RND procedure have evolved, and these were designed to reduce morbidity by
sparing nonlymphatic structures (modified RND) and to treat early nodal disease by removing only
the lymph node groups at greatest risk for harboring metastases (selective neck dissection).
Factors that determine the type of neck dissection include primary site, presence of clinical or
radiological neck disease, location of neck metastases and the primary treatment modality.
Common complications of a neck dissection include surgical site infection injury to
nerves, bleeding, and chylous leak.
SUGGESTED READING
K. Thomas Robbins, Sandeep Samant,and Ohad Ronen. Neck Dissection. In: Cummings CW, ed. Otolaryngology-Head
and Neck Surgery. 5th ed. St. Louis: Mosby, 2010:1702–1725.
Ah-See Kim, Supriya M. Neck Dissection. In: Watkins CJ, Gilbert RW, eds. Stell & Maran’s Textbook of head and Neck
Surgery and Oncology. 5th ed. Hodder Arnold, 2012:202–213.
Kerawala CJ, Heliotos M. Prevention of complications in neck dissection. Head & Neck Oncology. 2009;1:35.
Pai P. Complications in Head and Neck Surgery. Otorhinolaryngology Clinics: An International Journal 2010;2(1):61-67.

PERIAMPULLARY CANCER

-Dr. Anila T, Dr. Vivek Mangla

INTRODUCTION
Periampullary tumours arise within 2 cm of the major papilla and include pancreatic head tumours
involving the ampulla, tumours of the ampulla of Vater, the distal common bile duct (CBD), and
duodenal tumours involving the papilla.1

INCIDENCE
The incidence of periampullary cancers is relatively low and these make up for about 5% of all
gastrointestinal cancers. Pancreatic head tumours account for 40-60% of such tumours, while
tumours of the ampulla of Vater, the distal CBD and duodenal tumours constitute 10-20%, 10%
and 5-10% of periampullary tumours respectively.2 Carcinoma of the pancreas is now the fourth
most common cause of cancer death, following lung, colorectal and breast cancers.

RISK FACTORS
Risk factors for pancreatic cancer
Risk factors for pancreatic cancer are better understood than for ampullary, bile duct, and
duodenal adenocarcinoma.3 The important risk factors for pancreatic cancer include tobacco use,
obesity, red meat and heavy alcohol intake.

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 Chronic pancreatitis has been associated with pancreatic adenocarcinoma, but it is difficult to
determine whether there is a common risk factor for the two diseases or chronic pancreatitis is a
true risk factor for pancreatic cancer.
Familial clustering of pancreatic cancer accounts for approximately 10% of all cases. Only 20% of
familial pancreatic cancer cases occur as part of a named syndrome or have a defined underlying
genetic defect. The best characterized of these include BRCA2/ Fanconi anemia, familial atypical
multiple mole melanoma (FAMMM) syndrome and Puetz–Jeghers syndrome.
Risk factors for ampullary, distal CBD and duodenal cancers
Risk factors for ampullary, distal CBD, and duodenal adenocarcinomas are less well characterized
except that all demonstrate an increasing incidence with age. Incidence of ampullary and duodenal
adenocarcinomas is higher in patients with hereditary polyposis syndromes, including hereditary
nonpolyposis colorectal cancer, Peutz–Jeghers syndrome, familial adenomatous polyposis, and
Gardner syndrome. Cholangiocarcinoma is associated with several known risk factors, including
inflammatory bowel disease (ulcerative colitis), sclerosing cholangitis, and choledochal cysts.

CLINICAL FEATURES
Most patients with periampullary cancer present with the classic constellation of painless progressive
jaundice, pruritus, acholic stools, and high colored urine. Though fluctuating jaundice (due to sloughing of
tumour leading to partial relief in biliary obstruction) is sometimes seen in these patients, most often these
patients present with progressive jaundice (80%). Significant weight loss and abdominal pain are usually
seen in patients with advanced disease. These symptoms are to be differentiated from benign diseases like
biliary stone disease, biliary strictures, choledochal cysts and portal cavernomatous cholangiopathy.
Antecedent history of pain, with jaundice with bilirubin level <5mg/dl favours stone disease. A classic triad of
abdominal pain, lump in right upper quadrant, jaundice has been reported in children with choledochal cysts,
most adult patients do not have jaundice or a palpable lump at presentation. Upper GI bleed, splenomegaly
and obstructive jaundice indicate portal cavernomatous cholangiopathy. Patients with periampullary
neoplasms are susceptible to infection within the obstructed biliary system (known as cholangitis).
Cholangitis should be suspected when patients present with abdominal pain, jaundice, and fever with chills
(Charcot`s triad). A more fulminant presentation is described in which these patients develop a rapidly
progressive systemic illness that results in shock, coma, and death (Reynold`s pentad). All patients with
cholangitis should be aggressively resuscitated, and treated with broad spectrum antibiotics, and biliary
decompression done early after initial stabilization. Constitutional symptoms (weight loss, anemia) occur
early in patients with pancreatic cancer as these tumours tend to be larger at presentation. Patients with
ampullary cancer generally present at an earlier stage as their location results in biliary obstruction with
jaundice early in the course of illness (75%). Duodenal tumours more often present with abdominal pain,
iron-deficiency anemia, weight loss, nausea and vomiting than classic obstructive jaundice. The most
common presenting symptoms for distal CBD cancers are jaundice (90%), abdominal pain and weight loss
and these tumours also tend to present early.

Obstructive jaundice

Painless
Painful

BENIGN MALIGNANT BENIGN MALIGNANT

CBD stone Gall bladder cancer (50-
Mirizzi syndrome 70%)
Chronic pancreatitis with Pancreatic cancer (50-80%)
CBD stricture Hepatocellular cancer(40-
Choledochal cyst 60%)
Periampullary cancer (30-
40%)
Biliary stricture Periampullary cancer
Portal biliopathy Cholangiocarcinoma
Medical causes (e.g. Hepatocellular
Primary sclerosing carcinoma
cholangitis)

Physical findings on examination, includes icterus, excoriation marks (due to pruritis) and a palpable
gallbladder. Courvoisier lawstates that in the presence of a palpably enlarged gallbladder which is
nontender and accompanied with painless jaundice, the cause is unlikely to be gallstones. The
exceptions to this law should also be kept in mind. Signs of advanced disease include cachexia,
palpable metastatic lesions within the liver, palpable disease in the left supraclavicular fossa (Virchow
nodule), palpable periumbilical nodule (Sister Mary Joseph nodule), and pelvic metastatic disease
palpable anteriorly on a digital rectal examination (Blummer shelf).

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PATHOLOGY
Since pancreatic cancer compri ses nearly 40-60% of periampullary cancers, pancreatic ductal
adenocarcinoma is the most common malignant histology. Polypoid and papillary tumours are
associated with better outcomes. Further classification of periampullary carcinoma is based on
immunohistochemistry (IHC) of biopsy specimen into intestinal type and pancreatobiliary type.
IHC staining pattern is different for t hese two types: positivity for CD10, CDX2, M UC2, and CK20,
characterizes intestinal type whereas positivity for MUC1 and CK7 characterizes pancreatobiliary
adenocarcinomas. The intestinal t ype of periampullary adenocarcinomas are less aggressive and
are associated with better prognosis thaan pancreaticobiliary type cancers.

DIAGNOSIS AND PRE-OPERATIV E EVALUATION

The diagnosis of a periampullary cancer is made on the basis of clinical findings (as mentioned
above), laboratory data, and radiologic imag ing.
Biochemistry
Liver function tests reveal an obstructive pattern with raised direct bilirubin and a raised alkaline
phosphatase. Raised AST and A LT usually denote cholangitis, even though uncomm only, they
may be due to underlying liver disease ( chronic viral hepatitis, non alcoholic steatohepatitis e tc).
CA 19-9
The upper limit for normal CA 1 9-9 is 37 U/mL in most laboratories. It is not useful for the primary
diagnosis of pancreatic cancer but has a significant value as a prognostic factor a nd for follow up of
these patients. 4 Patients with a dvanced disease tend to have higher CA 19-9 le vels. However, in
patients with absence of function al Lewis enzyme levels of CA 19-9 are usually lo w resulting in false
negative results. In absence of biliary obstruction, intrinsic liver disease, and benign p ancreatic
disease, a CA 19-9 value of > 100 U/mL is highly specific for malignancy, (most often pancreatic
cancer). CA 19-9 has poor sensitivity for small, early stage pancreatic carcinomas and is ineffective
for early diagnosis of pancreatic cancer or as a scre ening tool. Patients with low levels of CA 19-9 (<
10 0 IU) are less likely to harbour occult metastatic disease. CA19-9 can be used as a marker for
recurrence in patients with an elevated pre-operative CA19-9 .

Imaging
1. Abdominal ultrasound (USG)
USG is frequently the initial imag ing modality for evaluation of patients with jaun dice. It reveals a
dilatation of the common bile duct till its lower end with dilatation of intra-hepatic bilia ry radicles. It
may also show an associated main pan creatic ductal dilatation and may help identify the pr esence of
possible metastatic disease especially in the liver. Ultrasound is easily available, inexpensive, a nd
does not entail radiation exposure. It helps detect stone disease. However, it is limited by the facts that
it is operator dependent and pancreas can be obscured by the overlying bowel gas.
2. Multi-detector CT angiography (MDCT)
MDCT with oral negative contrast (usually water mixed with mannitol) and intraven ous (iv)
iodinated contrast, performed by acquiring su b-millimeter axial section images in the pancreatic
and portal venous phase), is the preferred imaging modality for periampullary cancers. (Figure 1).
Chest and pelvis should be included in the scanned area fo r staging. Studies have shown that
70% to 85% of tumours deemed resectable by CT can be resected at surgery. 5 It must be
remembered that it is better to do imaging before any intervention (biliary ste nting) as the
presence of stent creates artifact du e to which a small tumour may be missed even on M DCT. CT
evaluation should include documentation of the tumor, its size, location, relation to superior m
esenteric artery and vein (abutment or encasement) and evidence of dissemination (liver,
peritoneal or omental metastasis, ascites). It also helps evaluate for arterial anomalies (e.g. celiac
stenosis, re placed right hepatic artery arising from SMA) which aid in surgical planning.

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Magnetic resonance imaging (MRI)
MRI is often done when there is a suspicion of biliary obstruction due to stone disease. MRI may
also be used to characterize the pancreatic mass or liver lesion in a patient with a pancreatic
mass, in young patients especially for follow-up (to avoid repeated radiation exposure), and in
patients in whom IV contrast cannot be administared. 6 Simultaneous presence of dilatation of the
CBD and the main pancreatic duct (MPD), the ‘double duct’ sign (Figure 2A) is seen in 77% of
pancreatic cancer and 55% of ampullary tumours. It is highly suggestive of periampullary
cancers.However, it must be understood that for patients with distal cholangiocarcinoma, MPD
dilatation may be minimal or completely absent (Figure 2B).
3. Endoscopic ultrasound (EUS)
Proximity of the pancreas to the EUS transducer placed in distal stomach /duodenum enables high-
frequency ultrasonography (7.5-12 MHz) to produce very high-resolution images. It is highly sensitive
and specific for diagnosing CBD stones. EUS is particularly helpful and recommended in patients with
suspected periampullary tumours in whom the mass cannot be seen on cross sectional imaging
(CT/MR).7 Another significant advantage is that it allows (EUS-guided) fine-needle aspiration from the
lesion, enabling cytologic confirmation of pancreatic carcinoma. EUS is similar to dual-phase, spiral CT
scanning for assessing resectability. It has to be understood that EUS needs expertise to interpret, is
still limited in availability and is required only in selective patients as mentioned above.
Endoscopic retrograde cholangiography and pancreatography (ERCP)
Even though ERCP findings of dilatation of both CBD and the main pancreatic duct (double duct
sign) is considered as pathognomonic, it is reserved for patients with cholangitis or some other
indication for pre-operative biliary drainage. A side viewing endoscopy (without ERCP) can be
done in these patients with or without a biopsy for confirmation of diagnosis.
Biopsy
It is not mandatory to have a pathologic diagnosis before surgery. It is required prior to administration
of chemotherapy in the setting of borderline resectable or unresectable pancreatic cancer (locally
advanced or metastatic disease) and in cases of diagnostic dilemma. Side viewing endoscopy with
biopsy is done for pathological assessment of ampullary and duodenal neoplasms. Fine-needle
aspiration (FNA) biopsy with either EUS guidance or CT may be done for pancreatic head lesions with
EUS-FNA being preferable to CT guided FNA in patients with resectable disease because of possibly
lower risk of peritoneal seeding with EUS-FNA compared to a percutaneous approach.8
6. Positron emission tomography (PET)
Role of PET is limited and not well defined at present for periampullary adenocarcinoma. It is not
routinely used presently in patients suspected of having a periampullary adenocarcinoma. 9
STAGING
AJCC, 8th edition (2016) has developed staging criteria for adenocarcinoma of the pancreas that
follow the tumour/node/metastasis (TNM) system.

T1 Tumour 2 cm or less
T1a - Tumour 0.5 cm or less
T1b - Tumour greater than 0.5 cm and less than 1 cm
T1c - Tumor greater than 1 cm but no more than 2 cm
T2 Tumour more than 2 cm but no more than 4 cm
T3 Tumour more than 4 cm in greatest dimension
T4 Tumour involves celiac axis, superior mesenteric artery and/or common hepatic artery
N1 Metastases in 1 to 3 nodes
N2 Metastases in 4 or more nodes
M1 Distant metastasis

Stage
Stage IA T1 N0 M0
Stage IB T2 N0 M0
Stage IIA T3 N0 M0
Stage IIB T1, T2, T3 N1 M0
Stage III T1, T2, T3 N2 M0
T4 Any N M0
Stage IV Any T Any N M1

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MANAGEMENT
Pre-operative biliary drainage
Routine drainage of biliary system before surgery is not advisable. Pre-operative biliary drainage is
recommended in patients with cholangitis, deranged renal functions, poor nutritional status, significant
co-morbid illnesses requiring stabilization and in candidates for neoadjuvant chemotherapy.
Endoscopic drainage (plastic stents or short metallic stents) is the preferred method of biliary
drainage. Percutaneous transhepatic biliary drainage should be considered for endoscopic failures.
Though some studies have shown better results with fully covered and removable SEMS even in
patients with resectable cancer (in terms of fewer stent blocks and chonagitis) than plastic stents.10,
we use SEMS in neoadjuvant or palliative setting considering the higher cost with their use.

Stage-wise management
Periampullary cancer can be broadly divided into the following 4 subsets for deciding the course
of management in these patients:
Resectable
Borderline resectable
Locally advanced unresectable
Metastatic disease

An expert consensus group has developed criteria to define tumour resectability, to improve
patient selection and the rate of R0 resection.11

Resectability Arterial Venous

status
Resectable No arterial tumor contact (celiac axis [CA],
superior mesenteric artery [SMA], or common
hepatic artery [CHA]).
Borderline • Solid tumor contact with CHA without
extension to celiac axis or hepatic artery
bifurcation
• Solid tumor contact with the SMA of ≤180°
or with variant arterial anatomy
Unresectable Distant metastasis (including non-regional
lymph node metastasis)
• Solid tumor contact with SMA or CA >180°
• Solid tumor contact with the first jejunal SMA
branch
No tumor contact with the superior mesenteric
vein (SMV) or portal vein (PV) or ≤180°
contact without vein contour irregularity.
Solid tumor contact with the SMV or PV of
>180° or ≤180° with contour irregularity or
thrombus of the vein
• Solid tumor contact with the inferior vena
cava (IVC).
• Unreconstructible SMV/PV due to tumor
involvement or occlusion (can be due to tumor
or bland thrombus)
• Contact with most proximal draining jejunal
branch into SMV

Staging laparoscopy
Staging laparoscopy may help avoid unnecessary laparotomy, in patients harboring occult metastatic
disease at the time of planned curative surgery.12 The benefit of staging laparoscopy therefore,
depends on the quality of pre-operative imaging and the likelihood of metastatic disease. Routine use
of staging laparoscopy is controversial. It should be considered in locally advanced cases on imaging
with indwelling biliary stents (resulting in relief in biliary obstruction) and without gastric outlet
obstruction. Its use has been suggested in the following situations in literature:
Tumors >4
cm Ascites
Marked elevated CA 19-9 (>1000 U)
Small indeterminate liver or peritoneal metastasis on imaging
Borderline resectable disease treated initially with neoadjuvant therapy
However, we as well as most other Indian centres do not routinely do a staging laparoscopy in
patients with periampullary cancers as these patients quite often benefit with biliary and gastric
bypass for lasting relief in biliary and gastric outlet obstruction in the event of finding of occult
metastatic disease at exploration.

1) Resectable disease
Pancreatico-duodenectomy (PD) remains the gold standard for management of patients with
periampullary tumors. The procedure is quite safe when performed in most high-volume centres
with an operative mortality of 1-5% in such centres. Even though the mortality from PD has
reduced drastically, overall morbidity remains high (30%) principally due to post-operative
pancreatic fistula, delayed gastric emptying, and post pancreatectomy haemorrage. 13

276
After preoperative evaluation and stabilization, with the patient in supine position and appropriate
incision (midline, bilateral subcostal, or right subcostal with midline extension based on patient
build and surgeon’s preference) made. Thorough exploration of the abdominal cavity is done to
assess and rule out metastatic disease.

Classic PD (Whipple’s procedure) entails en bloc removal of gall bladder, distal C BD, antrum,
entire duodenum, proximal jejunum alon g with pancreatic head followed by reconstruction (figure
4 A). In a pylorus preserving pancreatico-duodenectomy (PPPD), pylorus and first part of duode
num are preserved as shown in Figure 4 B.

Resection
Briefly, the procedure entails Kocherisation to mobilize the C loop of duodenum and pancreatic head is
done. Gastrocolic ligament is op ened to expose anterior surface of pancreas. Gastrocolic trunk is
identified, and ligated to expose SMV. Suprapancreatic dissection is started with ch olecystectomy and
later identification and division of G DA to expose suprapancreatic portal vein. Tunnel is created
behind the neck of pancreas with careful dissection. Gastric antrum is transected in conventional
pancreatico-duodenectomy. Duodeno jejunal flexure and proximal jejunum are mobilized and pr oximal
jejunum is transected and delivered to the right. In pylorus preserving pancreatico-duodenect omy
(PPPD), right gastric artery and right gastroepiplo ic arteries are preserved enabling preservation of p
ylorus and a bit of first part of duodenum. Two haemostatic prolene sutures are placed at inferior and
superior margin of the pancreas, on either side of the pr oposed line of transaction following which
pancre as is divided and hemostasis secured. Retracting th e specimen to the right and careful ligation
of the v essels from SMV, SMA, usually in a caudo-cranial direction is done subsequently. Surgeon’s
fingers guid e the left extent of the dissection by the SMA pulsati ons. This enables the final bit of the
resection wherein the uncinate process is separated from the SMA and SMV enabling removal of the
specimen. Figur e 5 A and B shows intra-operative photograph after co mplete resection.

Reconstruction
Reconstruction involves restoring the pancreaticoenteric continuity followed by biliary and
gastroenteric continuity.
Pancreatic reconstruction: It can be done with either a pancreaticogastrostomy or a
pancreaticojejunostomy. PJ (Figu re 5 C, 5 D) is our preferred technique for restoration of
pancreaticoenteric continuity. Some people prefer a pancreaticogastrostomy. Based on literature,
there is not much benefit of one approach over the other.

277
A leak from this anastomosis (post-operative pancreatic fistula) is directly or indirectly
responsible for most of the complications after a pancreaticoduodenectomy. No specific
technique has been able to eliminate development of clinically relevant postoperative pancreatic
fistula. Consistent practice of any standardized technique helps reduce pancreatic fistula.
Biliary reconstruction: End-to-side hepaticojejunostomy (HJ) is performed approximately 10-15
cm distal to the pancreaticoenteric anastomosis.
Enteric reconstruction: Gastrojejunostomy (GJ) is performed 30-45 cm distal to the
hepaticojejunostomy in either a retrocolic or an antecolic (our preference) fashion.
Feeding jejunostomy is done distal to GJ for post operative nutrition in the event of complications
arising from surgery.

Figure 5: Intra-operative photograph of a patient with periampullary cancer showing a PPPD

specimen (A), after complete resection (B), duct-to-mucosa pancreaticojejunostomy (PJ) in
progress (C) and completed PJ (D). Superior mesenteric vein (SMV), Superior mesenteric artery
(SMA)

Concomitant Vascular resection

En bloc resection of PV or SMV (partial or segmental) followed by reconstruction is feasible and safe in
case of portal venous/SMV involvement to obtain R0 resection.14 There is a higher morbidity and
mortality associated with arterial resections and therefore, these are not usually recommended.15
Role of adjuvant therapy following resection
Following resection, patients with node positive disease should be considered for adjuvant
chemotherapy to reduce recurrence rates. Chemotherapy options in this setting include
gemcitabine alone, 5-FU/leucovorin alone, and Gemcitabine + oral capecitabine.16 Gemcitabine
(alone or in combination) is preferred over 5-FU/leucovorin for most patients due to its more
favourable toxicity profile. Chemoradiation should be avoided after surgery except in setting of
clinical trials unless the margins are involved.
2) Borderline resectable disease
Routinely, a period of chemotherapy (gemcitabine/capecitabine or FOLFIRINOX) followed by
chemoradiation and then surgery (usually 4-8 weeks post completion) appears to be the best
option for such patients.17 Such patients should preferably be included in clinical trials Patients
should be restaged with abdominal and chest imaging followed by staging laparoscopy before
laparotomy after neoadjuvant therapy.
Locally advanced unresectable disease
A patient is considered to have locally advanced resectable lesion when the tumour is beyond the
criteria for borderline resectable tumours without any evidence of dissemination. Single agent
Gemcitabine is considered the standard of care in this setting.
4) Metastatic disease
Patients with metastatic disease often require interventions aimed at providing relief of biliary
and/or duodenal obstruction, malnutrition, and pain prior to initiation of palliative chemotherapy.

278
Non operative palliation
Biliary obstruction: For palliative/neoadjuvant chemotherapy, patient’s serum bilirubin should be
less than 3 mg/dL. Placement of a metallic biliary stent is helpful in palliating jaundice due to
biliary obstruction. Endoscopic stent placement is the preferred technique for this. Percutaneous
stent placement is an option for patients in whom endoscopy fails.
Duodenal obstruction: Duodenal obstruction is best managed with a self expandable metal stent
placed endoscopically which when possible, is favored over surgery.
Pain: Pain relief is an extremely important aspect in improving the quality of life in these patients.
Most patients with advanced disease have significant pain, which must be managed aggressively
Celiac plexus block (endocopy or fluoroscopy guided) is often helpful in palliating pain resulting
in a reduced requirement for oral/parenteral analgesics.
Operative palliation
Operative palliation should be considered in patients with advanceddisease who fail to respond to
above methods. Patients found inoperable at planned surgery should also be considered for
palliation of both gastric outlet and biliary obstruction.
Biliary obstruction:Amongst the surgical options for relieveing biliary obstruction, HJ is most effective
and should be considered in settings as mentioned above.18Other less effective operative procedures
include cholecystojejunostomy or T-tube insertion into the bile duct above the site of obstruction.
Cholecystojejunostomy is prone to recurrence of obstruction because the cystic duct insertion site
into the common bile duct is often close to the site of original obstruction. T-tube drainage results in a
controlled high-output external biliary fistula with its attendant implications in terms of fluid/electrolyte
loss in addition to the need to carry a drainage catheter.
Duodenal obstruction: Nearly 10% patients have gastric outlet obstrcution. GJ provides good
palliation in patients who either fail endoscopy or are found to have unresectable/metastatic
disease at exploration. Pain: Celiac plexus block should be given at surgery in patients found
unresectable at surgery. It can be done by injecting 20 mL of 50% ethanol or saline with a needle
on either side of the aorta at the level of the celiac plexus.
Palliative chemotherapy
Palliative chemotherapy does offer some survival advantage but at the expense of considerable
morbidity, cost and need for repeated hospital visits. The treatment needs to be tailored based on
performance status of patient, age and patient’s personal preferences.
If the performance status is ECOG 3/4, with significant co-morbidities and a very short life expectancy,
best supportive care without any chemotherapy should be considered. In patients with performance
status ECOG 2, and/or elevated bilirubin level, single agent gemcitabine should be considered. In
patients with ECOG 0 or 1 performance status and a near normal bilirubin, currently preferred
combination chemotherapy regimen options are FOLFIRINOX, gemcitabine+oxaliplatin,
gemcitabine + nab-paclitaxel.19,20
PROGNOSIS
Following resection, 5-year survival rate reported for duodenal carcinoma is 59% followed by ampullary
carcinoma with 39% and bile duct with 27%. Carcinoma pancreas has the least 5-year survival of 15%.
SURVEILLANCE AND FOLLOW UP
Following resection, these patients should be followed up every 3–6 months for 2 years, then
every 6–12 months with history and physical examination for symptom assessment, CA 19-9 level
(category 2B) and abdominal CT with contrast (category 2B).

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Lowenfels AB, Maisonneuve P: Risk factors for pancreatic cancer. J Cell Biochem 95:649, 2005.
Huang Z, Liu F. Diagnostic value of serum carbohydrate antigen 19-9 in pancreatic cancer: a meta-analysis. Tumour
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Walters DM, Lapar DJ, de Lange EE, et al. Pancreas-protocol imaging at a high-volume center leads to improved
preoperative staging of pancreatic ductal adenocarcinoma. Ann Surg Oncol 2011;18:27642771.
Schima W, Ba-Ssalamah A, Goetzinger P, et al. State-of-the-art magnetic resonance imaging of pancreatic cancer. Top
Magn Reson Imaging 2007;18:421-429.
Deerenberg EB, Poley JW, Hermans JJ, et al. Role of endoscopic ultrasonography in patients suspected of pancreatic
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guided fine needle aspiration in diagnosis of focal pancreatic masses. Endosc Ultrasound 2013;2:190-193.
Wang Z, Chen JQ, Liu JL, et al. FDG-PET in diagnosis, staging and prognosis of pancreatic carcinoma: a meta-
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Mollberg N, Rahbari NN, Koch M, Hartwig W, Hoeger Y, Büchler MW, Weitz J (2011) Arterial resection during
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BARIATRIC SURGERY
-Dr. Pawanindra Lal

The Burden of Obesity

Obesity represents one of the primary causes of preventable deaths. In 2014, an estimated1.9
billion adults were considered overweight and more than 600 million were obese, translating to
13% of the worldwide adult population. xiii Obesity is now a worldwide public health problem, an
epidemic, with increasing incidence and prevalence, high costs, and associated co-morbidities.xiv
The term “metabolic syndrome” (MS) is generally used to indicate the cluster of central obesity, insulin
resistance (IR), hypertension, and hyperlipidemia. Metabolic syndrome results in a greater risk of
developing T2DM and cardiovascular disease, 2 of the principal causes of death worldwide.xv

Bariatric surgery causes significant and sustained weight loss and can considerably reduce IR, with
dramatic clinical improvement or remission of insulin-resistant states (i.e., dyslipidemia, hypertension,
hyperuricemia, sleep apnea). Experimental evidence from animals shows that the effects of bariatric
surgery on insulin sensitivity and glucose homeostasis are not just the consequence of mechanical
reduction of food intake or energy absorption but derive from a variety of physiologic mechanisms,
including changes in gut hormones, biliary acids metabolism, nutrient sensing, and microbiota. xvi
This knowledge corroborates evidence of a critical role of the gut in glucose and energy
homeostasis and supports consideration of the gastrointestinal (GI) tract as a rational biological
target for interventions aimed at treating obesity, diabetes, and metabolic disorders. xvii

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Based on such mounting mechanistic and clinical evidence, conventional bariatric procedures are
now increasingly being proposed not only as mere surgical management of obesity but also as a
valuable approach to intentionally treat T2DM—a new concept and practice referred to as
“metabolic surgery.xviii WHO has classified obesity as:
BMI <18.5, it falls within the underweight range.
BMI 18.5 to <25, it falls within the normal.
BMI 25.0 to <30, it falls within the overweight range.
BMI is 30.0 or higher; it falls within the obese range.
Obesity is frequently subdivided into
categories: Class 1: BMI of 30 to < 35
Class 2: BMI of 35 to < 40
Class 3: BMI of 40 or higher. Class 3 obesity is sometimes categorized as “extreme” or
“severe” obesity.
Super Obese: BMI > 50

For the Asian population, Obesity has been modified by the Western Asia Pacific WHO as follows:xix
Class 1: BMI of 25 to < 29.9
Class 2: BMI of > 30

Gut microbiota
The human gut microbiota (GM) is a complex entity composed of more than 1000 species of
commensal microorganisms. GM is present across the GI tract with greater concentrations in the
ileum and colon.xxIn physiologic conditions, the GM contributes to intestinal system maturation,
host defense against pathogens, degradation of non-digestible polysaccharides and plays an
important role in body fat distribution and control of energy homeostasis. xxi
The GM is influenced by diet, lifestyle, physical exercise, antibiotics, and genetic background. xxii
GM modulates energy harvesting from dietary fibers, fat storage, lipopolysaccharides (LPS)
content, and the production of short-chain fatty acids which in turn regulate host food intake,
insulin signaling and Gut Adaptation to Bariatric/Metabolic Surgery (BMS).

Gut Adaptation to Bariatric/Metabolic Surgery

BMS is currently the most effective treatment for severe obesity and T2DM, providing sustained weight
loss as well as reduction and prevention of obesity-related cardio metabolic co-morbidities.xxiii Given
its dramatic clinical effectiveness, BMS provides an opportunity to better understand the role of the gut
in physiology and disease. In addition to weight loss, BMS can cause changes in various mechanisms
of GI physiology, including changes in satiety-promoting gut hormones (i.e., glucose-dependent
insulinotropic peptide, glucagon-like peptide 1 [GLP-1], peptide YY, and Oxyntomodulin) and increased
gastric emptying. Certain bariatric/metabolic procedures such as Roux-en-Y gastric bypass (RYGB)
and sleeve gastrectomy (SG) cause a shift in bile acids (BAs) metabolism composition, bile flow, and
increased BAs signaling through the BAs nuclear receptor Farnesoid X (FXR). GI modifications
imposed by certain procedures, particularly those involving a re-re-routing of the small intestine (i.e.,
RYGB, duodenal-jejunal bypass, DJB), can cause changes in microbiota composition and nutrient
sensing; all of these effects appear to be involved in the metabolic benefits of BMS.xxiv

Gastrointestinal hormones
RYGB and SG are characterized by an excessive postprandial response of the entero-endocrine
intestinal L cells responsible for a rapid increase in postprandial GI hormones.xxv The increase in GLP-
1 causes a rapid postprandial “incretin effect” increasing insulin secretion. This mechanism is thought
to be at least in part responsible for the improvement of glucose tolerance observed after these
procedures.xxviGhrelin, a hunger promoting hormone, is mostly produced in the stomach. Although no
specific pattern was observed regarding Ghrelin serum level changes following gastric banding, RYGB,
and bilio-pancreatic diversion, serum levels appeared consistently reduced after SG.xi

Bile acids
Beyond their role in the absorption of fat-soluble vitamins and dietary lipids, BAs are key
regulators of glucose and lipid metabolism as well as energy expenditure thanks to the interaction
with GM.iv The BAs are produced from cholesterol in the liver (primary BA). Primary BAs are
transformed into secondary BAs by GM in the intestine; these are absorbed in the terminal ileum,
returned to the liver, and are then secreted again into the bile (entero-hepatic cycle).

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Increased BA serum levels are observed after RYGB and SG, but not following gastric banding,
suggesting that elevated serum BA s levels in procedures that modify GI anatomy co uld improve
insulin sensitivity, incretin secretion, and p ostprandial glycemia. xxvii
Obstructive Sleep Apnea Syndro me
Obstructive sleep apnea (OSA) is linked to obesity and affects 15% of men and 6% of women. xxviii
OSA is characterized by airway obstructio n during sleep, responsible for chronic hypoxia; this
leads to the activation of the hypothalamic-pit uitary adrenal axis, causing oxidative stress, sys
temic and tissular inflammation (adipose tissue and liver), and increased secretion of pro-
inflammatory adipo-cytokines (Resistin, TNF-a, IL-6, plasminogen activator-1). These disturbances
result in decreased insulin sensitivity and pancreatic b-cell dysfunction. OSA is known as a
critical independent risk factor of cardiovascular disease, hypertension, MS, and T2 DM.xxix

TYPES OF BARIATRIC PROCEDU RES:

The failure of medical therapy for severe obesity and the success of surgery have, over the last six decades,
produced a remarkable s eries of new techniques and procedures for the tr eatment of obesity and its co-
morbidities. Bariatric operations have traditionally been divided into three groups based on their mechanism
of weight loss productio n. Malabsorptive procedures induce weight loss tot ally by interference with
digestion and absorption. Restrictive procedures produce weight loss solely by lim iting intake. Mixed
malabsorptive and restrictive proce dures limit intake and produce malabsorption.xxx
Table 1: Cl assification of types of Bariatric Procedures
Restrictive Alone:
Gastric Banding
Sleeve Gastre ctomy
Restrictive & Malabsorptive RYGB

BPD-DS
MGB

Jejuno-Ileal Bypass

Fig.1. Overview of bariatric surgical operations. (A) Jejunal-ileal bypass: end-to-end

jejunoileostomy with ileosigmoidostomy. (B) Biliopancreatic diversion with a d uodenal switch.
(C)Vertical banded gastroplas ty. (D) Roux-en-Y gastric bypass. (E) Adjustable gastric band.
(F)Sleeve gastrectomy.xxxi

ECONOMIC IMPACT OF BARIAT RIC AND METABOLIC SURGERY

Morbid obesity is associated with a myriad of serious co-morbid conditions, including h
ypertension, type 2 diabetes mellitus, and dyslipidem ia, osteoarthritis, and gallbladder disease.
xxxii
There have been numerous studies demonstrating th e effectiveness in obtaining weight loss
and marked resolution of co-morbidities with bariatric and metabolic surgery.xxxiii

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Based on scientific evidence, it is becoming increasingly clear and accepted that the on ly existing
therapy for severe obesity that has been shown to result in clinically significant and durable weight
loss is bariatric surgery. Furthermore, it has been shown that weight loss after bariatric surgery results
in significant improvements in obesity co mor bidity, quality of life, and reduced mortality. Sho rt- and
long-term complications of surgery, although not insignificant, appear to be reasonable and justifiable
compared with the long-term risks of severe obesity. Economic analysis has demonstrated that
bariatric surgery is cost-effective and perhaps cost-s aving in certain subgroups such as those with
type 2 diabetes. In addition, there is evidence that bariatric surgery may reduce indirect costs of obe
sity by improving workplace productivity and reducing absenteeism.xxxiv

Details of Commonly performed bariatric procedures

I. Laparoscopic Adjustable Gastric Banding (LAGB):

Fig 2: LAGB

Table 2. Potential comp lications of laparoscopic adjustable gastric banding xxxv

Band related Port tubing related

Slippage
Erosion Port displacement
Pouch dilatation Tube disconnection
Esophageal dilatatio n System leak
System leak Infection
Infection
Dysphagia
GERD

Although several definitions are available, failure of weight loss is usually defined as less than 50% excess
body weight loss.xxxvi Accor ding to these parameters, 10.5% of the patients wh o underwent LAGB
present with inadequate weight loss at 5 years and 14% at 10 years. Failure of weigh t loss remains the
most prevalent reason for conversio n surgery after LAGB in up to three fifths of the patients. xxxvii

LAGB is still regarded as a technic ally simple and relatively inexpensive bariatric surgi cal option.
Also, its safety is known in short-term and medium-term follow-ups. According to early studies,
LAGB offered significantly lower morbidities and mortalities compared with the standard of care
laparoscopic gastric bypass (mortality0.05% vs. 0.5%).
Even the weight loss outcomes of the LAGB were more than satisfactory compared with the potentially
more morbid LRYGB. If the initial weight loss was lower compared with the LRYG B, multiple
studies reported up to 65% EWL after 2 or 3 years. xxxviii

LAGB presents fewer short-term co mplications and shorter hospital stays than other bariatric
operations. Although its efficacy in terms of co-morbidity resolution seems adequate in many studie s,
the variability of results is such that without robust le vel 1data, final conclusions are difficult to draw.

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The main concern regarding LAG B remains with the long-term complications an durability of the
procedure. Overall it is fair to con clude that the role of the band seems limited at the moment.
The availability of more effective proce dures with acceptable short-term and long-term c
omplication rates, such as LSG, has eclipsed the role of the formally popular LAGB.iii
At MAMC we performed 10 bands a nd have had to revise 2 for failure and 2 for erosion.

Laparoscopic Sleeve Gastr ectomy (LSG)

LSG was initially created as the first step in a 2-part procedure (biliopancreatic diver sion with
duodenal switch) for super morbid obese pa tients in whom traditional bypass surgery was tho ught
too high risk based on their associated co-mo rbidities. Michel Gagner introduced this procedu re in
1999 as a standalone procedure for morbid obesity and there has been no looking back since. The
sleeve gastrectomy has since been found to have comparable results to other weight loss pro cedures,
including the Roux-en-Y gastric bypass, and has become an increasingly popular option among both
surgeons and patients. Advantages of laparoscopic sleeve gastrectomy over the roux-en-Y gastric
bypass includes acceptable use in patients with infla mmatory bowel disease, patients who are
transpla nt candidates (liver and kidney), and patients with complex prior abdominal surgery or
complex abdominal wall hernias. It is also a pylorus-sparing procedure that eliminates the risk of
dumping syndrome. Finally, there is no increased risk of marginal ulceratio n or internal hernias
compared with traditional bypass surgery. It is not, however, considered an anti-r eflux procedure.
Therefore, Barrett esophag us may be a contraindication.xxxix

Many variations exist regarding surgical technique; however, the basic tenets of LSG should be stringently
followed. These include pyloric preservation with gastrectomy beginning 2 c m to 6 cm proximal to the
pylorus, mobilization of the entire greater curvature with exposure and identifica tion of the left crus and
base of the right crus, avoidance of stricture at the gastric incisura, and proper apposition of the
anterior and posterior aspects of t he stomach when stapling to prevent a cork scre wing effect of the
sleeve and avoid a large retained fundic pouch.xxvii(Fig 3) Routine deep vein throm bosis prophylaxis
consists of sequential compression device placement and subcutaneous heparin.

Long-term follow-up has demonstrated durable weight loss and metabolic benefits com parable with Roux-
en-Y gastric bypass.xl. LSG evolve d from a staged procedure as part of the biliopancr eatic diversion and
duodenal switch and has emerged as a sole procedure for sustained weight loss an d improvement of
metabolic derangements. The surgery continues to gain popularity due to its p erceived technical simplicity
coupled with promising short-term and long-term data, which suggest res ults comparable to more
established bariatric procedures. The LSG has continued to gain popularity am ong both patients and
surgeons due to its perceived technical simplicity compared with other bariatric su rgical procedures. As
data regarding patient outcomes after this procedure continue to accrue among inst itutions, promising
results are being published more th an 5 years out from surgery. Most publications rep rt a mean
percent excess weight loss of 55% or more over this time period.xli,xlii

Fig. 3 – LSG xxv

LSG compares favorably to long-te rm weight loss data for laparoscopic Roux-en-Y gastric bypass over the
same time frame. Improvements of type 2 diabetes mellitus and metabolic syndrome abnormalities are also
similar compared with gastric bypass. Data pertaining to the improvement of gastro-esophageal reflux
disease or new onset of gastro-esophageal reflux disease after sleeve gastrectomy continue to evolve, and
dedicated objective stu dies are needed to better delineate this potential outcome.xliii

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Regarding the most feared complic ation, overall leak rates are reported between0.7% and 3.7%,
and a majority of these occur at the pr oximal third of the stomach staple line near the gastro-
esophageal junction.xliv

At MAMC, out of 100 total bariatric procedures we have performed 68 sleeve operations with results
comparable with the world literature. This procedure is successful so long as the patient is prepared to
follow up regularly and adopt life sty le changing measures, with effective resolution of co-morbidities.
Men tend to show a better long term success as compared to women in Indian setting.

Roux-en-Y-Gastrojejunostomy (R YGB)
The gastric bypass procedure wa s first introduced by Mason in 1967 as a variation of the Billroth II
reconstruction used after antrectom y in the treatment of peptic ulcer disease. xlvOver one-half of a century,
numerous modifications led to the elegant minimally invasive procedures we perform today. The most
noteworthy include the adoption of the Roux-en-Y configuration reported and advo cated by Griffin in
1977xlvi and the introduction of the laparoscopic Roux-en-Y gastric bypass (LRYGB) by Wittgrove
and associates in 1993.xlvii

Over the past 2 decades, the LRY GB has proven to be highly effective operation against obesity and its
associated co-morbid conditions, and has a favorable metabolic side effect profile wh en compared with the
more radical biliopancreatic diversion with duodenal switch. Numerous high-quality studies have
demonstrated the efficacy and safety of the procedure. It has since become and remains the gold
standard operation in the battle against the obesity epidemic. xlviii (Fig 4)

Fig 4 - Roux-en-Y gastric bypass.

COMPLICATIONS
There are multiple complications associated with the LRYGB, including but not li mited to bleeding, infection,
small bowel obstruction secondary to internal or port site herniation, marginal ulceration, anastomotic leak,
anastomotic stenosis or stricture, hypopharyngeal or esophageal injury, omental torsion or necrosis,
pulmonary embolus, d eath, development of symptomatic cholelithiasis, inadequate weight
loss, nutritional deficiencies, and symptomatic dumping syndrome. The incidence of specific
complications can vary with the te chnique used.xxxvi Anastomotic leak is a dreaded complication most
commonly occurring at the gastro-j ejunal anastomosis sitexlix, and with experience has reduced to 0-
3%.l. Stricture at the gastro-jejunal anastomosis is found to be reduced with the linear stapling
technique as compared to the circular stapler technique from the comparison of meta-analysis. li

LRYGB vs. Other procedures

LRYGB performed at specialty cen ters by fellowship-trained bariatric surgeons has excellent
outcomes with short durations of hospital sta y and low readmission rates. The 30-day mortality rate is
0.3% and major complication rate is 4.3%.lii T he LRYG is highly effective with regards to excess weight
loss when compared with other contemporar y procedures.liii The average excess weight loss fo
llowing LRYGB is 56% to 66% with average maintenance of 50%excess weight loss at 5 years.liv

Recently, emphasis has been pla ced on adherence to Enhanced Recovery after Bariatric Surgery
protocols. Enhanced Recovery after Bariatric Surgery interventions include shortened
preoperative fasts, intraoperative humidification, early mobilization and feeding, avoidance of
fluid overload, incentive spirometry, and use of prokinetics and laxatives. Short term studies
show Enhanc ed Recovery after Bariatric Surgery protocol adherence to be feasible and safe, and
results in shortened duration of hospital stay and low 30-day readmission rates.lv

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The LRYGB is the gold standard metabolic/bariatric procedure used today to combat the growing morbid
obesity epidemic. This procedure i s highly effective at reducing excess body weight and has substantial
efficacy against the multiple co-morbid conditions associated with obesity. There are varying techniques for
procedure performance as described. The most common technique today is a circu lar stapled gastro-jejunal
anastomosis with antecolic Roux limb and stapled jejuno-jenostomy with hand sewn common enterotomy
closure. Complications are associated to varying degrees with technique used.
It is important to be aware of th ese complications and be prepared for expeditious management.
Regardless of the technique used , the LRYGB performed at specialty centers by fellowship trained
surgeons with adherence to evi dence-based care protocols for peri-operative care has excellent
outcomes.xxxvi
At MAMC, we have performed this operation on two patients, both of whom are doing very well
and we strongly feel that long term monitoring of macro and micro nutrients makes this procedure
a challenging one to follow-up on long term basis in a country like India.

Bilio-Pancreatic Diversion with Duodenal Switch (BPD-DS)

The duodenal switch technique, without gastric resection, was originally described fo r the treatment of bile
gastritis, by DeMeester and colleagues in 1987. lvi In addition, Dr. Scopinaro and colleagues lvii described in
1979 a technique of bilio-pancreatic diversion. This procedure combined a distal gastrectomy, a gastro-
jejunostomy, and a jejuno-jejunostomy to create a 50-cm comm on channel and a 250-cm alimentary channel.
This technique resulted in excellent outcomes, but the rese ction of the pyloric valve and the short, 50-cm;
comm on channel resulted in post-gastrectomy syndrome, significant risks of marginal ulcer, and increased
gastr ointestinal side effects.lviii The technique was thus modified in the late 1980s, to perform a longitudinal
ga strectomy instead of a distal gastrectomy and to increase the common channel to 100 cm. lix By
preserving the pyloric valve and first duodenum, the norm al emptying of the stomach is preserved, the risk
of marginal ulcer is decreased, and gastrointestina l side effects are reduced. xivi In short, bilio-pancreatic
diversion with duodenal switch (BPD-DS) includes supplementations, decrease dissatisfaction with side
effects, and set reasonable goal expectations.

Fig. 5. BPD-DS. SG is performe d and the first duodenum is anastomosed to the last 250 cm of
small bow el. A 100-cm common channel is created.

A recent survey of the Internatio nal Federation for the Surgery of Obesity and M etabolic disorders member
national societies reporte d that the proportions of BPD-DS were 4.9% in 2008, 2.1% in 2011, and 1.5% in
2013.lx Even though the absolute number of BPD-DS procedures incre ased from 2008 to 2013, this suggests
that other surge ries are performed preferentially (i.e., SG, which has now become the predominant surgery
in North America).This decrease in the percentage of duode nal switch can be related to the lack of exposure
of many surgical teams to the BPD-DS technique, its reater complexity, and greater concerns about gastroi
ntestinal side effects and vitamins and protein defici encies. In addition, BPD-DS can only be offered to sup
er–morbidly obese patients (BMI above 50 kg/m2) in some countries.lxi

The complication rate after BPD-D S is usually higher compared with restrictive or mixe d procedure, such as
gastric bypass.lxii This is partly due to the complexity of the technique but also to BPD-DS being
specifically offered in super-obese patients with a higher rate of metabolic complicati ons.
Intraoperative strategies can be used to minimize surgical complications, including the use of SG
as a bridge to BPD-DS.
Postoperative management involve s active patient participation with follow-up and adherence to
dietary recommendations, including lifelon g vitamin supplements. The excellent long-term me
dical benefits and improvement in quality of life com e at the expense of some gastrointestinal
side effects and vitamin supplementation.xiix

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Mini Gastric Bypass (MGB)
In 1997, Robert Rutledge reported a simple version of the gastric bypass based o n the conventional Billroth
II gastrojejunostomy which general surgeons were very familiar with. This was named as mini gastric bypass
(MGB).lxiii Others re ported this as one anastomosis bypass (OAB), or s ingle anastomosis duodeno-ileal
bypass with sleeve ( SADI-S). lxiv This procedure was riddled with controversies in its initial years and
surgeons refused to gra nt it acceptance as a bariatric procedure. Howeve r, the ease of the procedure and
its effectiveness in a chieving weight loss and resolution of co-morbidities could not remain undiscovered by
surgeons across t he globe and in the last 10 years has taken the world by storm. The procedure involves the
creation of a sleeve like pouch from the level of the incisura of the stomach with anastomosis to a loop of
jejunum 2 00 cm distal to the DJ flexure. (Fig 6)

One of the most significant repor ts came from Taiwan in a prospective randomized controlled trial
comparing RYGB to MGB, which concluded that both LRYGBP and LMGBP are effective for morbid obesity
with similar results for resol ution of metabolic syndrome and improvement of quality of life. MGB is a
simpler and safer procedure tha t has no disadvantage compared with LRYGBP at 2 years of follow-
up.lxvControversies also arose due to the prolonged effect of bile in the stomach of suc h an operation and
possible increase in alkaline reflux. This concern was also laid to rest by a land mark study, which compared
LSG with MGB using high resolution impedance manometry concluded that I n contrast to LSG, OGB did not
compromise the gastr o-esophageal junction function and did not increase gastro esophageal reflux, which
was explained by the lack of increased gastric pressures and maintained gastro esophageal pressure
gradient.lxviAlthough the e fficacy of this procedure for proven for resolution of diabetes for BMI > 35,
another study also showed that MGB resulted in significant and sustained weight lo ss with successful
treatment of T2DM up to 87.1%. D espite a slightly lower response rate of T2DM treat ment, patients with
BMI <35 still had an acceptable D M resolution, and this treatment option can be offered to this
group of patients.lxvii

In our own experience at MAMC with 20 patients, we have found no difference in the occurrence of
GERD or any increased alkaline re flux before and after MGB using manometry and 24 hour pH
metry. These results also compared favora bly with those of LSG.

Fig 6. Mini Gastric Bypass sh owing a larger pouch like a sleeve anastomosed to a portion of
jejunum 200 cm distal to the DJ flexure.

Complications of Bariatric Proce dures (Table

Just like other surgical procedure s, bariatric procedures have their share of complications which are
common complications seen in other laparoscopic procedures as well. There are specific
complications due to the surgical steps of the procedure which are specific to each type of opera tion.
Diagnosis of complications in the early post-oper ative period can be challenging due to sheer size o
the abdomen and difficulty in eliciting any abdominal signs. Reliance is therefore mainly on heart rate
or pulse rate besides general condition. Pain has to be kept under control so that it does not produce
tachycardia and to prevent shallow breathing and the refore causing pulmonary atelectasis. Incentive
spirometry and early ambulation is the key to preventing some of the life threatening complications like
pneumonitis and DVT. Nutritional issues come up a bit late r after the patient is on home diet and
specific deficiencies are seen to occur depending on the type of procedure performed and degree of
malabsorption induced. Regular follow-up with the metabolic clinic is essential to keep these nutrients
under a tight cont rol with addition of supplements.

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Effects of Bariatric Surgery on Diseases
Although there is a lack of randomized controlled trials, there is an association between bariatric surgery
and risk reduction for cancer. This association seems to affect women in a greater way. Obesity’s link to
cardiovascular disease, diabetes, and certain cancers is clear and well documented. Obesity is also
associated with an increased risk of numerous other co-morbidities. In general, the risk of co-morbidity
increases as the degree of obesity increases. The risk of developing co-morbidity with increasing weight
varies by sex, racial/ethnic group, and genetic factors. lxviiiThe figures depict the body systems that are
impacted with obesity (Fig. 6).
In addition to increased mortality, obesity is linked to increased incidence of obesity related co-
morbidities. Multiple studies have demonstrated improvement/resolution of weight-related co-
morbidities (i.e., cardiovascular disease, diabetes, cancer, metabolic syndrome) after bariatric surgery.
Some researchers have demonstrated a level of recalcitrance in remission of diabetes, particularly in
patients with long-standing disease. More studies are needed to identify subgroups of patients that are
at risk for non-responsiveness to bariatric surgery. However, overall results are supportive of surgical
cure of obesity as a treatment of weight-related co-morbidities and mortality risk reduction.lxix

Revisional Bariatric Surgery

Revisional bariatric procedures are becoming increasingly common. Inevitably 5–8% of primary bariatric
procedures will fail requiring a revisional operation. The main reasons for revisional bariatric surgery are
either primary inadequate weight loss, weight recidivism, or inherit specific complications related to the
procedure itself. All bariatric surgical procedures, especially restrictive ones, are at risk for failure, from
either poor weight loss outcomes or procedural-specific complications. The most successful conversion
strategy relies on selecting the most appropriate revisional procedure, including one-stage versus two-
staged and laparoscopic versus open, and involving a multidisciplinary team approach to the patient. The
gold standard revisional option is usually to laparoscopically convert a restrictive operation like a Band or a
sleeve to a Roux-en-Y gastric bypass (RYGB) in order to have the best balance of long term weight loss,
resolution of complications related to the primary procedure and acceptable rate of peri-operative
complications.lxx Detailed discussion about these is beyond the scope in the current context.

Table 3: Complications & Follow-up after Bariatric Procedures

Peri-operative complications
1. Intra-operative
Entry onto peritoneal cavity
Small Bowel / Hollow organ
injury Solid Organ Injury
Anastomosis revision for tension/ischemia
Bleeding from Trocar site
2. Post-operative
Bleeding – Intraluminal or
extraluminal Obstruction
Infections
DVT
Embolism
Nutritional complications – Multiple deficiencies
Follow-up testing requirement based on procedure
LAGB: 6 months, 12 months, and annual
CBC, Comprehensive Metabolic Panel, Folate, PTH, Iron and transferrin, Vitamin B12, Vitamin D,
25-OH LSG: 6 months, 12 months, and annual
CBC, CMP, Folate, PTH, Iron and transferrin, Vitamin B12, Vitamin D,
25-OH RYGB: 6 months
CBC, CMP, Folate, PTH, Iron and transferrin, Magnesium, Phosphorus, Zinc, Copper, Vitamin B12, Vitamin D, 25-
OH
RYGB: 12 months and annual
Bone density: dual photon study, CBC, CMP, Folate, PTH, Iron and transferrin, Magnesium, Phosphorus,
Zinc Copper, Vitamin B12, Vitamin D, 25-OH
BPD-DS: 6 months
CBC, CMP, Folate, PTH, Iron and transferrin, Magnesium, Phosphorus, Zinc, Copper, Vitamin A, Vitamin
B1, Vitamin B12, Vitamin D, 25-OH, Vitamin E
BPD-DS: 12 months and annual
Bone density: dual photon study, CBC, CMP, Folate, PTH, Iron and transferrin, Magnesium, Phosphorus,
Zinc, Copper, Vitamin A, Vitamin B1, Vitamin B12,Vitamin D, 25-OH,Vitamin E

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 Table 4: Common points to remember for Bariatric Surgery
Gold Standard bariatric procedure– RYGB
Commonest performed procedure globally - LSG
New Emerging Proceddure – MGB
Dreaded complication after LSG – Staple line Leak near GJ
Serious complication after RYGB – Internal hernias
Long term complications – Multi-nutrient and protein
deficiencies Revision Bariatric surg ery - Laparoscopic
conversion of restrictive operation to an RYGB

Fig. 7 (A) Body systems impacted by obesity in Fig 7 (B) Body systems impacted by obesity in
females. (Copyright The Clev eland Clinic males. (Copyright The Cleveland Clinic
Foundation 2014.) Foundation 2014.)

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 LAPAROSCOPIC CHOLECYSTECTOMY
-Dr. Nitin Agarwal, Dr. Ravindra Budhwani

Introduction
Medical technology is proliferating at a good pace in India; this is especially true with regard to laparoscopic
surgery. The challenges for healthcare providers lie mainly with respect to adequate training of healthcare
personnel so that effective and safe use of technology is possible for a large number of patients. In ‘routine’
procedures like laparoscopic cholecystectomy, the expectations of the patient are and should be very high;
surgeons must understand this responsibility. The scientific uncertainties and empirical nature of healthcare
dictate that we cannot promise guarantees like the automobile or the airline industry; however, we should
minimize errors and offer minimum standards of care. Cholecystectomy can lead to complications that may
seem out-of-proportion to the index operation, viz, biliary stricture, cholangitis, biliary cirrhosis or liver
atrophy. This should ensure that due empathy and precautions are exercised at all stages, i.e., general
assessment, pre-operative work-up, intra-operative steps and postoperatively. The various measures can be
summarized in the following write-up.

General assessment and pre-operative work-up

The hospital and the clinical unit must be geared up to follow the WHO safety checklist to ensure that
wrong patient, wrong-site, or wrong-side surgery is near-eliminated. Patients of cirrhosis or liver
failure, cardio respiratory problems or renal dysfunction need cautious anesthetic assessment for
laparoscopy. Low pressure pneumoperitoneum (8-10 mm Hg) has been tried, but its routine use is
controversial. Predictors of difficulty (clinical, radiological) may guide a surgeon in deciding the
appropriate instrumentation or position on the list. Suspected biliary obstruction must be investigated
non-invasively and managed as per institutional policy. Thorough preparation of basic steps a day
before is essential for a trainee surgeon, if possible, use simulators to improve skills.

INDICATIONS:
Symptomatic cholelithiasis
Asymptomatic cholelithiasis ? Diabetes Mellitus (poor follow-up capacity, poorly controlled,
high risk of empyema), Sickle cell disease, TPN, Chronic Immunosuppression, Incidental
(young age, patient’s wishes)
Acalculous cholecystitis (biliary dyskinesia)
Gallstone Pancreatitis
GB polyp >1cm in diameter
Porcelain gallbladder

CONTRAINDICATIONS:
Absolute :
Refractory coagulopathy
Suspicion of carcinoma
Relative :
Previous upper abdominal surgery
Cholangitis
Diffuse Peritonitis
Cirrhosis or Portal hypertension
COPD
Cholecystoenteric fistula
Morbid Obesity
Pregnancy

History of the gall bladder disease along with co-morbid disease(s):

Nature and Severity of symptoms
Duration of symptoms
General physical examination of the patient.
Per abdominal findings on the basis of Clinical examination.
Routine investigations viz:
Complete blood count

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 Coagulation profile
Kidney function tests (Blood urea & Serum Creatinine)
Serum electrolytes
X-ray chest (P.A. view)
Electrocardiogram (ECG)
Specific Investigations viz:
U.S.G Abdomen
Liver function tests (Total bilirubin with Direct and Indirect bilirubin, Liver Enzymes)

On the day prior to surgery, patients are advised to take light diet and adequate sedation on the
night prior; fasting for at least 6-8 hours before surgery. Patients are advised to empty the bladder
before being shifted to the operation theatre. A single dose of prophylactic antibiotic, i.e. a second
generation cephalosporin, is administered during induction.
Laparoscopic cholecystectomy requires basic set of instruments which include:
Anesthesia equipment with monitors
Operating Table
Video Monitors
Suction & Irrigation
Electrosurgical unit with grounding pad equipped with current monitoring system
Laparoscopic equipment in a cart on wheels
Light source
Insufflator
Camera Processor Unit
Instrument table with following laparoscopic instruments
No. 15 scalpel blade and handle
Veress needle and Hasson’s cannula
Gas insufflations tube
Fiber optic cable to connect laparoscope with the light source
Video camera with cord
Set of haemostatic forceps
Trocars and Cannulas
Atraumatic graspers
Locking tooth grasper
Maryland dissectors curved
Scissors
Right angle dissector
Clip applicator with clips
L – Hook Dissector
Spatula
Operation Theater planning:
Position of the patient: Supine, monitors are placed on the right side of the patients near the head end.
Endotracheal tube along with naso-gastric tube was placed after the induction of anesthesia. Surgeon stands
on the left side of the patient with the first assistant (camera person); in the French technique the surgeon
may stand between the lithotomized legs. The staff nurse (with second assistant-in four port technique)
stands on the right side of the patient. The second assistant is required in four port technique for the
retraction of the gall bladder fundus during the operative procedure. For the sake of brevity, we have not
discussed reduced-port strategy or Single Incision Laparoscopic Surgery (SILS) here.

Two 10 mm trocars (supra-umbilical for camera port and epigastric port) and two 5mm trocar
(right mid-clavicular line subcostal region and right anterior axillary line umbilical level). I prefer to
place the umbilical trocar first, then the epigastric under vision slightly right of the midline
through the top half of the falciform ligament, then the umbilical level trocar for retraction of
fundus. This allows me to avoid puncturing the branch of the inferior epigastric artery and also,
customization of the subcostal port based on the position of the neck of the GB.
Pneumoperitoneum is created by insufflating carbon dioxide through closed technique (Open
technique uses Hassan cannula vide infra). Here, a spring-loaded Veress needle with
protective blunt tip is inserted via a small 10 mm incision above the umbilicus with the
patient in 15 degree Trendelenberg position.

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The anterior abdominal wall is kept lifted during the time when veress needle is inserted. The
intraperitoneal location of the needle is confirmed by the saline drop test, where in saline is drawn
into the peritoneal cavity by the negative pressure. Once the needle is confirmed in the peritoneal
cavity, the carbon dioxide gas is insufflated. The usual preset intra-abdominal pressure used is 12
mm of Hg with the flow rate of 10 litres per minute. The amount of gas used for insufflations
before the start of surgery is 1.2 – 1.5 liters.

Open vs closed technique

– Not very different (safety-wise)
–Use open technique to familiarize oneself with dissection for level II laparoscopy
(TEP, nephrectomy)
– Overall time will be the same (closer faster and easier in open method)
Using Veress needle: precautions
– Check the needle
– Beware of umbilical hernia/ adhesions
– Customize penetration angle
– Tests for intraperitoneal entry (use the monitor)
<5mm Hg and >0.5 L/min
Percussion and aspiration
Symmetrical distension
Be vigilant for extraperitoneal insufflation

Special considerations for adhesions (more for experienced surgeons)

– Palmar’s point/ 9th-10th intercostal space entry
– Optical trocars
– Initial placement of 5 mm canula

Primary port placement : While elevating the anterior abdominal wall manually, 10 mm cannula is
inserted through the same incision used for creating pneumoperitoneum. Trocar is inserted,
directed towards the pelvis. A 10 mm Telescope is placed through the primary cannula and
peritoneal cavity is inspected for injury. The liver is inspected and the state of the gallbladder is
noted. The falciparum ligament, left lobe of liver and stomach is also inspected. The patient is
placed in the reverse Trendelenberg position (usually 15°) and the table tilted to the left to allow
a clear view of the gallbladder area, due to falling away of right colon and small bowel.

Secondary port placement: An epigastric 10 mm port is placed about one-third the distance
between the xiphoid and umbilicus (a high port gives optimal working space in Indian patients),
entering the peritoneal cavity under direct vision to the right of the falciparum ligament by
applying even pressure and no sudden jerky movements. Another 5 mm port is placed under
direct vision in the mid-clavicular line 2-3 cm below the right costal margin. Fourth port (5 mm)
is placed in the anterior axillary line at a point about level with umbilicus (vide supra).
The stomach is deflated to allow good vision and prevent inadvertent thermal injury. Once
the secondary ports have been established, instruments are used to perform dissection
through the epigastric port and midclavicular port, inserting a grasping forceps through
the fourth port and and grasping the upper edge/ fundus of the gallbladder, pushing in
cephalad direction anterior to the liver towards right shoulder.
All the adhesions are separated and the gallbladder is cleared and neck of the gallbladder reached.
Tense GBs can be aspirated at this point; the colon may be carefully avoided if there are omental
adhesions. Hemostasis is important during dissection so that light remains bright for the
subsequent steps.A hook electrocautery/ Maryland dissector can be used to divide the peritoneal
layers that cover the infundibulum and cystic duct by blunt stripping action. The aim is to dissect
posteriorly and elongate the GB pedicle as very few variations are seen posteriorly.
Dissection of the Calot’s Triangle: Dissection starts high up in the neck of gallbladder and
is kept close to the gall bladder until the anatomy is well-defined.Hook dissector can be
used to liberate the lower portion of gallbladder from its attachment to liver, both laterally
and medially. The narrowing of the gallbladder infundibulum into the cystic duct is clearly
defined in its entire circumference by:
Anterior dissection in Calot’s region using L-hook
A clear view of cystic duct by complete exposure of continuum of posterior cystic
duct going upto infundibulum and the lower portion of gallbladder

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 During dissection of cystic duct, the cystic artery is generally identified slightly cephalad to
cystic duct. After identification, it should be clearly elevated with either a Maryland
dissector or hook so at least 1 cm is dissected completely from surrounding structures.
A large window of space is created behind the gallbladder, the infundibulum and the
cystic duct and cystic artery – “Critical view of Safety”. The choice of instruments and
energy sources remains with the surgeon and is guided by cost and availability. Apply
two ligaclips on distal portion of cystic duct and one clip as close to the gallbladder as
possible under direct vision and divide the cystic duct with scissors; preferably, the
cystic artery should be dealt with similarly but later, to avoid possible avulsion.
Dissection of gallbladder from liver bed: Dissect the gallbladder off the liver bed using monopolar
cautery (hook/ spatula) starting behind the Hartman’s pouch. During the dissection gentle
traction is applied to the gallbladder. The assistant can rotate the fundus to allow triangulation
and stretching of the areolar tissue. The gallbladder is not completely removed from its liver
bed, and, by leaving the fundus attached, the liver can be inspected along with the gallbladder
fossa carefully for accessory cholecystohepatic ducts of Luschka and bleeding. Using
irrigation and suction, the liver bed is closely scrutinized and dealt with as necessary. Inspect
the cystic duct and cystic artery at this stage to ensure that the clips are in position.
Extraction of the Gallbladder: Insert the large grasping forceps through the epigastric port to hold
the neck of the gallbladder which is then extracted partially through the port. If the stones are
large, crush them within the gallbladder or extract in parts through the epigastric port using
ovum forceps. After removal of the gallbladder, liver bed is inspected once again.
In case of bleeding or bile spillage, a non-suction drain 14/16 Fr is placed in the sub-hepatic pouch
of Morrison’s, inserted through the 5 mm port and positioned under vision. Few surgeons now insert
drains routinely. Remove the secondary ports under vision. The table is straightened and the gas is
expelled. The skin incisions are closed with cosmetic 3-0 sutures and the patient is shifted to the
recovery room. In uneventful cases, the patient may go home as a day case.

Intra-operative safety
– Reduced-port strategies are for experienced surgeons
– Break up operation into steps
– ‘Anxiety is good’
– Use the grips and angles which suit you best
– Keep the field dry
– Use of electrosurgical units (burn-pull-burn)
Use only when required
Fulguration and dessication (BLUE) commonly used
Ergonomics
– Left hand is the key
– Trocars towards GB, avoid blood vessels on the parietal wall
– Modify trocar sequence as per the case
– Right and left hand angle as wide as possible
– Operating end of instruments seen at right angles to telescope
5th port and NG tube if necessary
Posterior dissection is essentially partial retrograde dissection and lengthening of
duct (posterior anomalies rare)
Liver should be visible through ‘window’
GB-cystic duct junction more important
Elephant’s head and trunk
Clipping
– Grip
– Make sure end is visible
– Withdraw away from clip
– Don’t clip stones in the cystic duct
– When in doubt→ Suture
Role of Intra-op. Cholangiography is doubtful today; not used in most centers.
Difficult to justify and advocate partial cholecystectomy laparoscopically
For spilled stones, use retrieval bag.
Suspect CBD when
– Horizontal course to D2
– Not occluded by large clip, 2 ducts, large artery behind, too much dissection

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 Conversion is not failure
Take informed consent always
Criteria for conversion
– Unclear anatomy (Mirizzi’s, short cystic duct etc.)
– Failure to progress ..time??
– Injuries: vessels, viscera, bile duct
– CBD stones not managed at the present set-up laparoscopically

Postoperative safety
LFT’s when in doubt
Rely only on overall clinical picture
For day cases, have a written communication explaining all possibilities
When leak is suspected, DRAINAGE is the key
Always ask the patient to discuss HPE report with you
In difficult cases, serial LFT’s for 6 months

REMEMBER
Learn at least ONE point from all teachers
Define standard steps for your own technique
Break up surgery into STEPS
Posterior dissection and lengthening of cystic duct is the key
Clip only when sure
Left hand is the surgeon: right is the facilitator
Conversion is not failure

CURRENT STATUS OF MANAGEMENT OF CBD STONES

-Dr. Jagdish Chander

During the era of open cholecystectomy the management of common bile duct stones (CBDS) was
relatively straightforward, but with the advent of laparoscopic cholecystectomy (LC) in 1980s, the
treatment of CBDS, whether recognized preoperatively or peroperatively remains controversial.
Treatment options include selective preoperative endoscopic retrograde cholangiopancreatography
(ERCP), open choledochotomy, intraoperative ERCP with endoscopic sphincterotomy (ES),
postoperative ERCP with ES, and single stage laparoscopic clearance of CBD stones.
HISTORY
In first part of the 19th century, surgery of the biliary system consisted of attempts to duplicate what
nature had shown to be effective treatment: creation of cutaneous fistulas and delayed enteric fistulas.
The introduction of ether anesthesia in 1846 ushered in the era of modern biliary surgery and the first
successful removal of a gallbladder. It was not until 1890 that the first surgical exploration of the
common bile duct (CBD) was performed by a Swiss Surgeon, Ludwig Courvoisier, who removed a
gallstone via an incision in the CBD, 8 years after Langenbuch reported the first cholecystectomy. 1
ThenThorton and Abbe reported their experiences with direct incision into the CBD to remove calculi. 2The
next important milestone was the introduction of intraoperative cholangiography in 1932 by Mirizzi. 1 This
procedure resulted in two effects. First, it reduced unnecessary bile duct explorations. Second, it reduced
the incidence of retained stones, which was associated with high reoperative mortality.
The introduction of endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic
sphincterotomy (ES) by gastroenterologists from Germany and Japan in the 1970s, led to a
revolution in the treatment of CBDS. This method soon became the treatment of choice for
managing choledocholithiasis.2
Berci was pivotal in the development and dissemination of first the rigid, and later the flexible,
choledochoscopy.1 By the 1980s, the use of intraoperative choledochoscopy was widely
disseminated and proven to reduce retained stones in an additional 10% to 15% of patients that
otherwise would have been missed.3,4
All was well in the world of biliary surgery until 1989, and the treatment of CBD calculi was
relatively straightforward.

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Patients suspected of harbouring CBD stones underwent intraoperative cholangiography. If CBD
calculi were discovered, the bile duct was opened and the stones retrieved. If there were too many
or they could not all be retrieved, a biliary enteric anastomosis was performed.
The biliary world turned upside down with the introduction of therapeutic laparoscopy. Preoperative
diagnostic endoscopic retrograde cholangiography (ERC)/endoscopic sphincterotomy (ES) became the
standard for patients suspected of having choledocholithiasis to avoid conversion to open CBD
exploration (CBDE). Postoperative ES became the preferred approach for the treatment of common
duct stones encountered at surgery or discovered afterward.5,6
Efforts to treat patients with common duct stones in one session and avoid the potential complications of ES
(especially in younger patients with small-diameter CBDs) resulted in several laparoscopic techniques of
transcystic CBD exploration (LTCBDE) including lavage, trolling with wire baskets or biliary balloon
catheters, cystic duct dilation, ampullary balloon dilation, biliary endoscopy, and stone retrieval with wire
baskets under direct vision, even antegradesphincterotomy and lithotripsy. Almost concurrently in 1990s,
the technique of laparoscopic CBD exploration using a choledochotomy was also described. 6This technique
was the laparoscopic replica of the open procedure that many surgeons were well versed with. The trans
choledochotomy approach was especially useful in cases where the stone size was too large, or the stones
were too many or the cystic duct morphology was unfavourablefor the trans-cystic route.
INCIDENCE
Common bile duct stones are a fairly common entity. Between 3% to 18 % of patients undergoing
Laparoscopic Cholecystectomy (LC) for gallbladder stones have synchronous CBD stones.7,8
CLINICAL PRESENTATION
The symptoms and signs of CBDS are highly variable and can range from patients being
completely asymptomatic, to complications such as cholangitis or pancreatitis. 9
The prevalence of asymptomatic CBDS has been found to be between 5.2% and 12%. 10 A common
presentation of CBDS is the biliary colic. Pain is often situated in the right hypochondrium or epigastrium
and can last from 30 minutes to several hours, with associated symptoms such as nausea and vomiting.
Other common symptoms include jaundice along with pale stools and dark-coloured urine.9
Two serious complications of CBDS are cholangitis and gallstone pancreatitis. Acute obstructive
cholangitis is a life-threatening complication caused by an infection of the biliary ductal system
secondary to biliary obstruction.9 In cholangitis, the classic symptoms of Charcot’s triad may be
encountered, and the less common Reynold’s pentad adds to the diagnosis.9 Despite the
advancement in treatment, acute obstructive cholangitis still carries a mortality rate of 10–20% .11
DIAGNOSTIC INVESTIGATIONS
The preoperative evaluation for CBD stones should include a careful history, biochemical tests and
abdominal ultrasonography. It seems reasonable to avoid further diagnostic preoperative
investigations and routine intraoperative cholangiography in patients with absence of jaundice, normal
liver function tests, and ultrasonographic evidence of a normal biliary tree (CBD diameter <9 mm). 12
However, investigation of the group at risk is necessary. If there is any suspicion that preoperative
choledocholithiasis is present, magnetic resonance cholagiopancreatography (MRCP) or endoscopic
retrograde cholangiopancreatography (ERCP) is performed. ERCP should be performed only in patients who
are expected to require an intervention; it is not recommended for use solely as a diagnostic test. 12
LABORATORY TESTS
Patients exhibiting the symptoms described above require diagnostic investigations to assess for the
presence of CBDS.13 Liver function tests (LFTs) can be used to screen for CBDS. Elevated serum
bilirubin and alkaline phosphatase typically reflect biliary obstruction, but these are neither highly
sensitive nor specific for CBDS.14Various studies have proven elevated serum gamma
glutamyltranspeptidase (GGT) and alkaline phosphatase (ALP) to be the most frequent abnormalities in
laboratory values of patients with symptomatic CBDS.9 Most of the studies have shown that laboratory
studies must be used in addition to imaging modalities to predict the likelihood of CBDS.14
IMAGING MODALITIES
Transabdominal Ultrasonography (TAS)
It is the first line investigation in patients with suspected CBDS. 9 Its sensitivity for detecting CBDS
is between 25% to 63%, with a specificity of approximately 95% depending on the degree of
dilation of the CBD and investigator’s experience.9,13
Endoscopic retrograde cholangiopancreatography (ERCP)
ERCP is often described as the gold standard test to for the detection of CBDS. This procedure was initially
used primarily in diagnosis, but today is more commonly used as a therapeutic modality. 13 ERCP has
sensitivity between 90% to 95% in detecting CBD stones and a specificity of 92% to 98%. 13,15
Christensen et al. demonstrated that the ERCP has a morbidity rate of 15.9% and a mortality rate
of 1%.16

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Percutaneous Transhepatic Cholangiography (PTC)
It is an invasive procedure where the intra hepatic biliary system is cannulated under radiological
guidance followed by instillation of dye through a percutaneously placed needle. It is not a routine
initial diagnostic test in patients with CBD stones but is the modality of choice in patients with
previous gastric surgery, distal obstructing CBDS that failed ERCP or in patients with cholangio
hepatitis and extensive intrahepatic stone disease. 17
Endoscopic Ultrasound (EUS)
It involves the endoscopic insertion of an ultrasound probe through the stomach and up to the second half
of the duodenum, allowing for ultrasound images of the CBD without the interference of subcutaneous fat
and bowel gas.18It allows application of the ultrasound transducer directly against the luminal surface,
thereby enhancing image quality. The proximity of the transducer to the target tissue also permits the use of
higher frequency ultrasound, which further contributes to the enhanced image resolution. Sensitivity of EUS
varies from 95 – 97%, while specificity is between 95–98%.18,19 EUS is significantly more sensitive than TAS
in detecting CBD stones. Its sensitivity is comparable to the diagnostic ERCP, while its major advantage is a
significantly decreased morbidity compared to ERCP.18
Magnetic Resonance Cholangiopancreatography (MRCP)
It has emerged as an accurate, noninvasive diagnostic modality for investigating the biliary ducts.20 It
may be especially beneficial in identifying patients who would benefit from early intervention. 12 A
meta-analysis of 67 published controlled trials shows that MRCP has an excellent overall sensitivity of
95% and a specificity of 97% for demonstrating CBDS.21 Some major disadvantages of MRCP, as
compared to ERCP, are the lower spatial resolution, potential for claustrophobia, and the inability to
evaluate patients with pacemakers or ferromagnetic implants.20,21
Intraoperative Cholangiography (IOC)
This technique involves instillation of contrast into the biliary tree through the cystic duct, and the
visualization is done using fluoroscopy. The routine use of IOC is still controversial. Some authors
supporting routine IOC, while others favour selective IOC, and others report no advantages in IOC with
respect to missed CBD stones.12However, it can be an useful tool to identify choledochal stones. 12 This
procedure can be performed during open or laparoscopic cholecystectomy. IOC has a sensitivity of 98% and
specificity of 94% to detection of CBDS.22 IOC can fail primarily due to inability to cannulate the cystic duct,
leakage of contrast fluid during the injection, air bubbles mimicking stones, failure to fill the biliary tree
because of too rapid contrast injection into the duodenum, and spasm of the sphincter of Oddi.
Reports have shown that this procedure ensures fewer retained stones, fewer postoperative
ERCPs, and a reduction in the number of CBD injuries. 9,12,22 One drawback is lengthening of the
operative time by approximately 15 minutes.12,22
Intraductal Ultrasonography (IDUS)
The technical evolution of EUS has lead to the development of small calibre intraductal ultrasound
(IDUS) miniprobes (about 2 mm), which can be passed through standard endoscopes directly into the
bile or pancreatic duct. The small calibre, flexibility, and excellent image quality produced by these
catheters makes them ideal for evaluating a variety of biliary disorders. IDUS is capable of producing
better image resolution than standard endoscopic ultrasound. Acoustic coupling is optimized by the
tubular anatomy of the bile duct, which is fluid filled and only slightly larger in calibre than the probe
itself. In addition, the probes operate at higher frequencies (12 to 30 MHz) than standard EUS, which
leads to higher image resolution. Although the utility of intraductal ultrasonography (IDUS) for common
bile duct stones has been reported, the clinical significance of this procedure in making therapeutic
decisions has not been well clarified.23 IDUS is a valuable method for residual small stones in the
common bile duct after endoscopic lithotripsy.23,24 IDUS increases sensitivity and specificity in the
diagnosis of choledocholithiasis, and these gains are not translated into a notable increase in
procedure time (7–15 minutes).24 IDUS is especially recommended in patients who have a dilated bile
duct with suspected small bile duct stones when ERCP is not diagnostic.24
MANAGEMENT OPTIONS
No consensus exists regarding the ideal management of gallbladder and CBD stones. CBD stones
can be detected preoperatively, intraoperatively or postoperatively. Consequently the
management options are quite varied especially in the present era of advanced laparoendoscopic
techniques. The following management strategies are available:
Endoscopic Sphincterotomy (ES) with stone extraction followed by laparoscopic cholecystectomy.
Simultaneous endoscopic stone extraction with laparoscopic cholecystectomy
Combined laparoscopic cholecystectomy and CBD
exploration(LCBDE) Open CBD exploration
ES post cholecystectomy

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Other methods include electrohydraulic lithotripsy (EHL), extracorporeal shockwave lithotripsy
(ESWL), laser lithotripsy, and dissolving solutions that are indicated only in special situations.
Every procedure has its advantages and disadvantagesand there is a broad overlap between the
indications for anideal management option in a particular clinical scenario.
Therapeutic decision making is based on the local availability of expertise. Twogroups of
interventions have significant roles in management of CBD stones:
Pre- or postoperative ERCP with endoscopic biliary sphincterotomy (ES) in a two-stage procedure,
Surgical bile duct clearance and cholecystectomy as one stage procedure – open or laparoscopic.
Several randomized controlled trials showed similar effectiveness for both methods of treatment. 25,26It
has been reported that one-stage management of symptomatic CBDS is associated with less morbidity
and mortality (7% and 0.19%) than two-stage management (13.5% and 0.5%).26
Open CBDE
Open exploration for CBD stones was the traditional treatment for management of this disorder.
However, with the advent of laparoscopic surgery in general, and laparoscopic CBD exploration in
particular, fewer than ever procedures are being done through the open approach worldwide.27 The
advantages offered by the laparoscopic approach over the open approach include, among many
others, lesser postoperative pain and discomfort for the patient, faster postoperative recovery and
significantly shorter hospital stay. The patients are able to return to the activities of daily living much
faster compared to the open technique. However, there still remain few situations in which the open
route is preferable over the laparoscopic approach, and these include non availability of the
expertise/equipment, unfavourable biliary anatomy, large impacted stones in the CBD and other
general contraindications to laparoscopic surgery.12,27 Preoperative ERCP
The success rate for stone clearance is 87% to 97% but upto 25% of patients require two or more
ERCP treatment.28The associated morbidity and mortality rates are 5% to 11% and 0.7% to 1.2%
respectively. Moreover, ERCP is not possible in 3% to 10% of all patients.26Complications of
ERCP include bleeding, duodenal perforation, cholangitis, pancreatitis and bile duct
injury.26,28Schreurs et al. showed 75%– 84%patients undergoing ERCP/EST had no symptoms
with upto 70-month followup.29 Intraoperative ERCP
It is another option for removal of CBDS, particularly stones in the common hepatic duct or intrahepatic
system. The use of intraoperative ERCP is effective but is associated with logistic and technical difficulties. It
requires additional equipment and additional personnel availability in the OT during the
procedure. The patient’s position may be suboptimal for the endoscopist to perform endoscopy,
identify the papilla and cannulate it.26,28
Postoperative ERCP
Postoperative ERCP is done for intraoperatively diagnosed CBD stones during laparoscopic
cholecystectomy when the expertise to perform laparoscopic CBD exploration is not available. The patients
are usually taken up for ERCP in the same admission and the success rates of removal of stones
vary from 55 to 80%.28 However, the dangers include all the complications of ERCP and the dilemma of
managing CBD stones in ERCP failure because a third procedure would then be needed.26,28
Laparoscopic CBD exploration
Laparoscopic exploration of the CBD via the transcystic route was first reported in 1991.1,2 Laparoscopic
choledochotomy and CBD exploration also was first reported in 1991 but has been less widely
documented.2Berci and Morgenstern, in the multi-institutional SAGES study, documented the procedure for
laparoscopic extraction of CBDS in 1994.30 In 1999, Cuschieri et al. in the EAES study concluded that the
laparoscopic single-stage approach for management of gallstone disease and choledocholithiasis is the
preferable option in fit patients31. However, the dissemination of this procedure has been limited.
For the transcystic exploration, a balloon angioplasty catheter (8 Fr) is used to dilate the cystic
duct and CBD stones are visualized using either IOC and fluoroscopy or direct visualization using
a choledochoscope. CBD stonesare removed using trolling with wire baskets or balloon catheters
or flushed into duodenum by saline lavage.30
For the transcholedochal route, a choledochotomyis made in the
supraduodenal part of the CBD. Intraoperative choledochoscopyis usually
performed to visualize and remove the CBDS under vision and to check for
the completion of removal at the end of the procedure. An additional 5-mm
port inserted at the highest point in the epigastrium in the right paramedian
position for choledochoscopy of the lower CBD.32The calculi are extracted by
using a Dormia basket under choledochoscopic vision. Impactedstones can
be broken under direct vision using intracorporeal lithotripsy with Holmium
laser, and the fragments can be flushed through the ampulla into the
duodenum with hydrostatic pressure.32

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Closure of the CBD can be done in several ways depending on the merits of each case.In case of concern of
residual debris, extensive inflammation, or manipulation or spasm of the ampulla, closure over a drainage
tube is preferred. This can either be in the form of an external drainage (T-tube), or internal drainage (endo-
biliary stent).32 In cases with no residual debris or any inflammation of the CBD primary closure of the duct
without any drainage is preferred. Choledochotomyis generally closed using continuous sutures of 4-0
polygalactin, although some surgeons may prefer an interrupted closure.32For
CBDs > 20 mm in size and/or impacted CBD stones, laparoscopic choledochoduodenostomyis preferred
creating a stoma of at least 20 mm, using single layer of interrupted sutures of 3-0 polygalactin.32,33

The successful laparoscopic management of CBDS is dependent on several factors including surgical
expertise, adequate equipment, the biliary anatomy and the number and size of CBD stones. Successful
stone clearance rates for LCBDE range from 85% to 95% with a morbidity rate of 4% to 16% and
mortality of 0% to 2%.32,34A metanalysis of 1762 patients who underwent LCBDE from 19 studies
worldwide showed a mean duct clearance of 80% with average morbidity of <10% (4–16%) and
mortality of <1% (0–2.7%).35Also, transcystic stone clearance may have a recovery very similar to
laparoscopic cholecystectomy alone as it is a more anatomical approach. 34,35
Laparoscopic transcystic common bile duct exploration (LTCBDE) vs laparoscopic
choledochotomy32
LTCBDE Lap choledochotomy
Skill Endoscopy Lap suturing
Stones (number) <8 Any number
Stone Size (mm) <9 Any size
Stone Location Distal to cystic duct Entire duct
CBD diameter (mm) Any >9
Drain Optional Suggested
Contraindication Friable cystic duct Small-diameter CBD
Intrahepatic stones
Multiple, large stones
Advantages No T-tube T-tube for postop access
Shorter hospital stay
Quick
Disadvantages Equipment Lap suturing
Intensive new skills required T-tube

In our series of laparoscopic CBD exploration, which is the largest such

series published from south east Asia, the majority of patients had stones
between 5 to 15 mm.32 As a result of the large average stone size and
number transcholedochal route was used in the majority of patients. The
average duration of surgery was 139.9 ± 26.3 (range, 90–205) min and the
conversion rate is 4% which is one of the lowest reported in the published
literature.32 Fifteen percent of our patients had nonfatal postoperative
complications ranging from wound infection, transient hyperamylasemia,
bile leakage, intra-abdominal collection, and upper gastrointestinal
hemorrhage. There were three cases of retained stones (2%), all of which
were managed effectively with postoperative ERCP. Postoperative stay
ranged from 2 to 33 days with an average of 4.6 ± 4.1 days. Eighty-one
percent of the patients had a stay of 5 days or less.32
The ideal method of CBDS removal is the one that does not cause injury to
the sphincter of Oddi, because it is desirable to preserve the sphincter in
patients younger than aged 60 years.32,36 One-stage management of CBDS
with LC and LCBDE has lowest morbidity and mortality and is cost-effective
with a short hospital stay.27 It treats both gallstones and CBDS in single
stage compared with staged procedures, and can be performed as a day care
procedure.27,35 LCBDE also preserves the function of sphincter of Oddi
and hence reflux-related complications, such as cholangitis and
recurrent stones associated with sphincter damage, are not seen. 32,36
The mean number of procedures needed per patient for complete clearance
of CBDS has been reported as 1.46 with ERCP ± ES and 1.23 with
LCBDE.26,31

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Extra corporeal shock wave Lithotripsy (ESWL)
ESWL was first used for treating gallstones in 1980s following its successful use in fragmenting renal
calculi.9 ESWL involves the percutaneous administration of sound waves directed at the liver and bile duct. It
is not performed during endoscopy, but rather before an ERCP in hopes of shattering large stones
into smaller, more manageable fragments. European studies evaluating ESWL report duct
clearance rates of 83% to 90%, but its acceptance elsewhere has been slow.9,12
Dissolution techniques
These solutions are instilled either directly into the biliary tree or are administered orally, absorbed by GIT
and then secreted in the bile. They do not cause irritation of the biliary tree and are not toxic. Every
dissolution therapy will last for several weeks, therefore the ideal solvent has not yet been produced. 37The
use of ursodeoxycholic acid (UDCA) and chenodeoxycholic acid has only been shown to dissolve
cholesterol-containing stones. Approximately 85– 95% of patients in the west will have cholesterol stones.
Continuing therapy with UDCA appeared to prevent recurrence of gallbladder microlithiasis. 9 Methyl-
Tertbutyl-Ether (MTBE) is an excellent cholesterol solvent that has been shown to work faster, but it is toxic
to liver and duodenal mucosa. It has been proposed by several studies that using dissolution in combination
with endoscopic retrieval or lithotripsy has better outcomes.9,12,37

Percutaneous extraction
This technique is used for non operative extraction of CBD stones when ERCP has failed or has
not been possible due to an altered anatomy and an inaccessible papilla. As a preliminary
procedure, a percutaneous transhepatic cholangiography is performed and stones are visualized.
Percutaneous transhepatic balloon dilation of the papilla of Vater is then performed and the
stones are pushed out into the duodenum using a Fogarty balloon catheter. 38If the stone diameter
is larger than 15 mm, then basket lithotripsy is performed before balloon dilation. The procedure
has a success rate of 80 - 96% in CBD stones and in 55 - 61.5% in intra hepatic stones.38
Complications described for this procedure include cholangitis, subcapsularbiloma, subcapsular
hematoma, subcapsular abscess, bile peritonitis, duodenal perforation and CBD perforation.38

Endoscopic versus laparoscopic removal

Endoscopic methods, such as ERCP ± ES, need an experienced and skilled endoscopist to be
successful.26 Even after ERCP, ES is not always possible, and when ES is successful the duct is
not always cleared of stones.25,26
Although useful, the endoscopic procedures are not without cost, morbidity, mortality, and significant
lifestyle disruption. It has been seen that ERCP increases total cost to twice that of LCBDE. 26 For ERCP ± ES,
the stone clearance rates are 65–75% after one session and increase to 85–92.5% after three sessions.39 The
success rates decrease in patients with altered anatomy, such as intradiverticular papilla,
abnormal localization of papilla, retropancreaticstenosis of bile duct, Billroth II bypass, and Mirizzi
syndrome.26,39
ERCP ± ES has a morbidity of 7.6–13.5% and includes the risk of pancreatitis, bleeding, perforation,
cholangitis, delayed stricture of sphincter, residual/recurrent stones, papillary stenosis, and
mortality of 0.4–0.55%.25,26
Preoperative ERCP also causes bacterial contamination of CBD.12,26 It has been seen that all recurrent
stones after ES are bilirubinate type regardless of the type of initial stones, indicating a role of reflux with
infection due to ablation of the sphincter.12,25,26 Post-ES stricture of the sphincter with proximal residual
dilatation of CBD also has been postulated to cause stasis of bile and recurrent stone formation. 26,39Late
papillary stenosis is observed between 10and 33%, with recurrent stone formation and
subsequent cholangitis.9,26
With advancing technology, laparoscopic biliary surgery has become safe, efficient, and cost-
effective.40 Randomized trials, comparing two-stage (pre- or postoperative ERCP/ES and laparoscopic
cholecystectomy) versus single stage (laparoscopic cholecystectomy with LCBDE) reported similar success
rates.30,31,39 Laparoscopic CBD exploration was associated with successful stone clearance rates ranging
from 75 to 95%, morbidity of around 10%, and mortality of approximately 1.5%.30,32,40 Patients
treated by LCBDE had a significantly shorter hospital stay and lower hospital cost compared with those who
underwent a two-stage procedure.30,31,39Cuschieri et al. concluded that laparoscopic treatment was
preferable for ASA II and ASA III patients, whereas ERCP/ES was indicated for high-risk patients.31
The morbidity rate after ES followed by LC ranged from 3 to 16% (mean 13%), whereas after laparoscopy
it ranged from 7 to 19% (mean 8%). The mortality rate after ES ± LC ranged from 0 to 6% (mean
2%) and was twice higher the rate after laparoscopy, which was 1%.12,30,39

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CURRENT SCENARIO
Stones Diagnosed Preoperatively
The general trend of management of preoperatively diagnosed CBD stones has been by ERCP with
stone extraction with stenting if indicated, followed by laparoscopic cholecystectomy. However single
stage LCBDE is emerging as a primary and cost effective treatment modality with less morbidity.30,31,39
In elderly and unfit patients, ERCP and stone extraction from the CBD is the initial and probably
the definitive treatment. It is also the initial treatment in patients presenting with jaundice,
cholangitis or severe pancreatitis. Laparoscopic cholecystectomy is undertaken once the
condition of the patient has improved. Biliary stenting is advocated for patients with large dilated
CBD, multiple impacted stones or stones not completely removed by ERCP. 12
For patients who are fit for surgery, the choice is between single stage operative exploration of CBD or a
sequential approach i.e. preoperative or postoperative ERCP with ESalong with laparoscopic
cholecystectomy. ERCP has a morbidity rate of 5 to 9.8 % and a mortality rate of 0.3 to 2.3 %, mostly due
to post procedural acute pancreatitis, duodenal perforation and bleeding.31 Moreover it causes
injury to the sphincter of Oddi which should be avoided in patients younger than 60 years. 26,32,36
Recent studies indicate that one-stage management of CBD stones with LCBDE has less morbidity and
mortality and is cost effective with a short hospital stay. 26,39 It treats both gallstones and CBD stones in
single stage compared with sequential procedures, and can also be performed as a daycare procedure. 40
LCBDE also preserves the function of sphincter of Oddi and hence prevents reflux-related
complications, such as cholangitis and recurrent stones associated with sphincter damage.26,32,36
Performing ERCP along with LC implies organizational problems concerning the availability of an
endoscopist in the operating theatre whenever needed. Finally, performing ERCP after surgery
would raise the dilemma of managing CBD stones whenever ERCP fails to retrieve them because
a third procedure would then be needed.36
Reference centres for laparoscopic surgery currently propose treating both gallbladder and CBD
stones during the same laparoscopic procedure.30-32,36 No consensus has been achieved
concerning the best approach (laparoscopic or endoscopic) because the laparoscopic
management of CBD stones has not had a wide diffusion till now.In situations where there are
difficulties in performing a combined laparoendoscopic procedure or the laparoscopic experience
is limited, it is safer to perform an ERCP followed by cholecystectomy. 36
A number of studies have reported about themid-long-term results of laparoscopic CBD exploration, with
excellent results reported upto 15 years post surgery.27,41-44These studies have also pointed out the
advantage of the laparoscopic approach over the endoscopic approach in maintaining an intact sphincter of
Oddi, thus obviating the drawbacks of bile reflux in the lower end of the surgery in the long term. This is
especially more important in case of young patients, where the incidence of post procedural bacteriobilia
and recurrent stones has been linked to loss of the function of sphincter and the accompanying
reflux into the lower end of the CBD.27,44

Stones Discovered Intraoperatively

The available options are; (a) total laparoscopic clearance, (b) combined laparoendoscopic
treatment, (c) conversion to open CBD exploration, and (d) post cholecystectomy ERCP.
If the surgeon is experienced the most appropriate treatment would be a total laparoscopic
approach. Several cohort studies have shown that two thirds of the stones detected by
intraoperative cholangiography can be removed via the transcystic approach. 45However this may
not be true in Asian population where the CBDS are often large, multiple and densely impacted in
the CBD. For patients in whom transcystic extraction of CBD stones fails, laparoscopic
choledochotomy and stone extraction may be performed. However, this approach requires
experience in laparoscopic suturingand a CBD of adequate diameter.
A Cochrane systematic review by Martin et al. concluded that a single-stage treatment of bile duct
stones via the cystic duct approach was recommended for intraoperatively discovered CBD
stones.26 In patients where it is not possible to clear the duct by this approach, a delayed
postoperative ES should be the preferred option in most centres.
The other alternative to immediate treatment of CBD stones discovered at surgery is delayed
treatment. Surgeons can insert a biliary stent through the cystic duct into the CBD and through
the sphincter of Oddi.26 This procedure ensures access to the bile duct for postoperative ES.

Stones Discovered Postoperatively

These patients are best managed by endoscopic clearance,which is considered as the least morbid
procedure. Failurerates of upto 10 % have been reported. 26,31 In these situationsthe treatment options are
either laparoscopic or openexploration depending on the surgical expertise and resourcesat disposal.

302
LESS
Laparoendoscopic single-site (LESS) surgery has emerged as an alternative to conventional
laparoscopic surgery with some proven benefits.46Many clinical applications of LESS surgeries have
been reported in the fields of gynecology, urology, and general surgery. Although laparoscopic CBD
exploration has a high rate of stone clearance rate and low morbidity and mortality, this technique
requires the acquisition of suturing and knot tying skills.46 Suturing and ligation are more difficult in
LESS surgery, compared to conventional laparoscopic surgery due to the angle limitations.
Robotic
Recent developments in laparoscopic CBD exploration have focused mainly on implementation of
robotically assisted surgery and new imaging methods.47 Since FDA approval of the da Vinci
robotic system (Intuitive Surgical, Sunnyvale, CA, USA) for general surgical procedures, several
reports have addressed their application for biliary surgery. Most surgeons gain their first clinical
experience with surgical robots when performing cholecystectomies. The da Vinci system
currently is the most widely used robotic system.
CONCLUSION
The best treatment for choledocholithiasis is the one that is simple, reliable, readily available, and cost-
effective for most patients. With advances in technology and an increasing experience in laparoscopic
techniques making LCBDE feasible and safe, this has emerged as the favourable choice in the hands of
experienced laparoscopic surgeon. The benefit of avoiding a preoperative ERCP, in an otherwise
healthy patient with choledocholithiasis, is that it excludes the hazards associated with ERCP and
keeps the ampulla anatomically intact. Moreover, the benefits of minimally invasive surgery can be
extended to the subset of patients with large and/or multiple CBDS which are otherwise unfit for ERCP
and ES and have to undergo open procedures for stone removal.
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Sivac MV. EUS for bile duct stones: how dose it compare with ERCP? GastrointestEndosc (2002) 56: S175–S177.
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Hallal AH, Amortegui JD, Jeroukhimov IM. Magnetic resonance cholangiopancreatography accurately detects
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AN INTRODUCTION TO INTERVENTIONAL RADIOLOGY

-Dr.Pushpinder S.Khera

Interventional Radiology (IR) is a branch of Radiology that deals with minimally invasive treatment of
various diseases using image guidance.
The two broad categories of IR are:
Nonvascular IR
and vascular IR
The former includes procedures such as percutaneous drainage of intrabdominal/intrathoracic
abscesses/collections, percutaneous biliary drainage (PTBD) (Fig 1), percutaneous nephrostomy
(PCN), image guided (ultrasound, CT, Fluoroscopy) sampling (biopsy and fine needle aspirations).

304
 Fig 1. A case of hilar cholangi ocarcinoma for whom a PTBD has been perform ed from the left
approach.
The spectrum also includes percutaneous ablation of visceral tumors (hepatocellular carcinoma,
carcinoma lung, renal cell carcinoma) using radiofrequency or microwave energy.
Radiofrequency ablation of osteoid osteomas is an established procedure as well (Fig 2 ).

Fig 2.An osteoid osteoma of the left humerus in a 12 year old girl treated by
Radio frequency ablation(c)
Image guided interventions also in clude various pain relief procedures e.g. facetal blo cks, neural
blocks and caudal block for neuralgic pain.
The vascular interventional (end ovascular radiological) procedures rely upon obtaining a safe
arterial/venous access to the vascu lar tree of the body using Seldinger’s technique an d
subsequent to it using a multitude of hardware(cath eters, microcatheters and wires along with
disease and organ specific agents such as embolic material, a ngioplasty balloons, stents etc) for
treating a gam ut of pathologies.It has a role in virtually every branch of medicine.

Interventional neuroradiological applications:

Aneurysm coiling by Intterventional Radiologist offers a minimally invasive alternative to
surgical aneurysm clippin g with comparable procedural risks and long term results. Some
locations of the aneurysm e.g. posteriorly directed basilar top, poster orly directed ant
communicating artery, ane urysm involving a major arterial branch, dissecting fusiform
aneurysm are either difficult or impo ssible to treat surgically without high risks. These
can be treated by endovascular methods.(Fig 3)
Dural aretrio-venous fistulas (DAVFs) are a pathology centred in the dural leaves with
abnormal communication between meningeal arteries and dural veins/sinuses. As a result
of their usual location at skull ba se they are more amenable to interventional trea tment
rather than surgery. Carotico caverno us fistula(CCFs) are a specific form of DAVFs in
which the venous communication occurs bettween carotid arteries and cavernous sinuses
leading to dramatic symptoms such as pulsatil e exophthalmos, chemosis along with a
risk for loss of vision.They too are amenable to endovascu lar treatment.(Fig 4)

305
 Arterio-venous malformattions (AVMs): Trans arterial embolization of cerebr al and spinal
AVMs has an established role in treatment of these pathologies either alone or in
combination with surgery and sterotactic radiotherapy.
Stroke reperfusion: Stro ke is a major cause of morbidity/mortality in both developing and
developed countries. Mechanical thrombectomy whereby the thrombus from intracranial
circulation is aspirated using a suction or stent retrieval device is the cornerston e of treatment
in a patient who has a NIHSS (National Institutes of Health Sciences Scale) score >7 at 3-6 hrs
with presentation beyond the 4.5 hr window for iv-tPA(intravenous tissue plas minogen
activator) infusion therapy. This treat ment can be instituted upto 6 hrs after start of ictus.
Carotid artery revascularisation/Carotid artery stenting: It is a viable non- surgical alternative
to a patient with hemodyna mically significant carotid bulb/ICA plaque causing recurrent
transient ischemic attacks (TIAs).
Pre-operative embolizati on of highly vascular tumors such as glomus tumors and juvenile
angiofibromas helps the surgeon to minimize the blood loss during surgery. For maximum
benefit and minimizing the risk of tumor lysis syndrome the embolization should be done
within 24 hours of the planned surgery.

Fig 3: Non contrast CT brain sho ws diffuse subarachnoid haemorrhage in a 60 y ear old male
with no history of trauma (a).Diagno stic cerebral angiogram (b) shows a large aneury sm arising
from anterior communicating artery (arrow).The same was treated by coili ng(c).

Fig 3. A case of left carotico-cavernous fistula shows opacification of

cavernous sinus and its tributaries(inferior pet rosal sinus and superior
ophthalmic vein) on DS A of the internal carotid artery(a).Coiling o f the
cavernous sinus(b) leads to closure of the fistula(c).Pre and post procedure im
ages(d and e) show marked improvement in the symptoms.

306
Aortic and peripheral arterial/venous applications:
Endovascular treatment of complex aortic aneurysms and dissection offers a safer and
simpler option to difficult su rgical treatments. Aortic stent grafting for traumatic aortic
transections is a lifesaving procedure in emergency settings.
Recanalization of periphe ral arteries in chronic thrombotic occlusion of limb vessels(iliacs,
femorals and infrapopliteal vessels) by endovascular means (angioplasty and stenting)
helps in management of peripheral arterial disease patients by re-establishing the a rterial
flow to the limbs, thereby saving the l imb from further ischemia, improving the quality of
life for the patient and also avoiding amputati on.(Fig 5)

Fig 5.CT angiography (a ) and baseline DSA (b) shows complete occlusion of the left
common iliac artery. Rec analization of the same has been done by stentin g(c).
Acute limb ischemia/critical limb ischemia: In selected cases catheter dir ected thrombolysis
by urokinase /t-PA infusion obviates the need for an embolectomy.
Peripheral arterio-venous malformations (AVMs): Trans arterial injection of sclerosants such as
absolute alcohol is usef ul in staged procedures to cause sclerosis and decrease in size of the
malformations. However one has to guard against using > 10 ml of alcohol in o ne sitting.
Varicose vein ablation(b y laser/ radiofrequency energy) and perforator sclerotherapy is now
established as a m inimally invasive alternative to venous strippin g and perforator
ligation.(Fig 6)

Fig 6. Pre (a) and 1 month post treatment(b) of varicose ulcer by laser ablation of great
saphenous vein.
May Thurner syndrome presents as unilateral venous edema of the left leg in young individuals
which may progress to reca lcitrant ulceration. It is treatable by stenting of the left iliac vein.

Gastrointestinal system:
Transarterial chemoembolisation(TACE) for hepatocellular carcinoma is an established
palliative treatment for In termediate stage (BCLC classification) hepatoc ellular
carcinomas whereby chemotherapeutic drug (Adriamycin) is delivered within the tumo r
by trans arterial route(Fig 7)

307
 Fig 7.TACE done for a right lobe HCC (a) shows deposition of lipiodol and
chemotherapeutic drug in the tumor (b).
Transarterial radio-embo lisation (TARE) for hepatocellular carcinoma is useful as an
alternative to TACE in cas es where latter can’t be done due to portal vein in vasion by
HCC. In this procedure radioactive beads containing Yttrium-90 are delivered in the tu mor
vicinity leading to cellular death by the beta rays emitted by the radio-isotope.
Transjugular intrahepatic porto-systemic shunt (TIPSS): It has an importa nt role in treatment of
refractory ascites and hydrothorax in chronic liver disease by creating a p arenchymal shunt
through liver extending from right hepatic vein to right branch of portal vein (Fig 8).
This reduces the hepatic venous pressure gradient(HVPG) thereby decreasing intraperitoneal
accumulation of fluid. It is also a life saver in bleeding oesophageal varic es which can’t be
controlled by endoscopic b anding or re bleed early (within 48 hours) after banding.

Fig 8: Transjugular int rahepatic porto-systemic shunt involves placing a

stent(arrow) extendin g from the hepatic vein into the portal circulation .

Hepatic venous outflow obstruction (Budd Chiari syndrome): It has a varied presentation
depending on whether the obstruction to venous outflow from liver is present at the
hepatic venous level or at supra hepatic IVC level. Interventional Radiology has a major
role in its management by doing hepatic vein angioplasty with stenting and IVC angiopla
sty with or without stenting. These procedure increase the venous outflow from the liver
via the hepatic veins and collaterals(Fig)
BRTO (Balloon occluded retrograde transvenous obliteration) for bleedin g gastric varices is a
transvenous procedur e that involves placing an occluding balloon in the gastrorenal renal
shunt(GRS) and injecting a sclerosant within the gastric varices.
It is very useful in patients with large (>2 cm) sized gastric varices which are difficult to treat by
endoscopic glue injection. In addition refractory hepatic encephalopathy is also an established
indication for BRTO since it occludes the systemic shunting from portal flow.
Gastrointestinal bleeders : Pseudoaneurysms in the setting of chronic pancreatitis, trauma,
vasculitis etc are treatable by endovascular approach by using agents such as coils, glue etc

Genitourinary system
Post-partum haemorrhage: Uterine artery embolisation using gel foam, PVA (polyvinyl
alcohol) particles and at times glue is extremely useful in severe non responding cas es of
post-partum haemorrhage which may b e due to uterine atony, placental accreta or prese
nce of a vascular injury. The major advant age of this procedure is that it preserves the
uterus while the corresponding surgical opti on is hysterectomy.

308
 Uterine artery embolisati on for fibroids: It is uterus preserving option for treatment of fibroids in
younger females. The i deal candidate is a lady who has menorrhagia due to an intramural
fibroid, has completed her family and still has few years to go for her menopaus e.
Iatrogenic renal bleeder : Post PCNL renal pseudo aneurysms are e asily treatable by
interventional radiology me thods in a minimally invasive manner with preservation of
vascular supply to the non-involved portion of kidney (Fig 9).

Fig 9 (a) A post PCNL re nal bleeder is evident as a pseudo aneurysm

(arrow) on selective right DSA.(b) The same is treated by super selective
coiling without aff ecting vascular supply to rest of the kidney.

Varicocele and pelvic co ngestion syndrome: The two entities have a similar pathology in form
of an exaggerated reflux into the gonadal veins from renal vein/IVC leading to distended
gonadal veins. The interventional treatment involves permanent occlusion of gonadal
veins by coils and sclerosants.
Pelvic trauma: Embolisati on of bilateral iliac arteries by gel foam/PVA is a lifesaving
procedure in hemodynamically unstable cases of pelvic trauma

Bronchial artery embolis ation is useful both as an emergency as well as ele ctive procedure to
cure massive and recalcitra nt recurrent hemoptysis respectively. The patient profile in most
cases is post tubercular cases ha ving hemoptysis due to bronchial artery hypertrophy.
Pulmonary arterio-venou s malformation is a rare indication for intervention in cases where the
patient presents with recurrent infections and hemoptysis.
Musculoskeletal system
Pre-operative embolisati on of large osteosarcomas and chondrosarcomas help to minimize
blood loss during surgery.
Percutaneous sclerother apy for slow flow venous malformations helps to c ause sclerosis
and decrease in size of the lesio n over multiple sittings.
Disclaimer: The contents of this abstract give a brief overview of the various interventional
radiological procedures. The reader should refer to standard textbooks nd journals for
indications, procedural steps and complications of specific procedures.

MANAGEMENT OF DUODENAL ULCER PERFORATIO N

-Dr. Sushanto Neogi

The earliest reported cases of duodenal ulcer were done by Travers in 1817, but Mikulicz gave the first
operative description in 1884. It took another decade for the first successful repair. Annually around 4
million people are affected by peptic ulcer disease of which 10- 20% develop complications. 2-14% of
these complications will be perforations. The clinical significance of this entity is that m ortality to the
tune of 10-40% especially in South East Asian and African subcontinent is still encount ered. The
western literature reports more peptic ulce rs in women in advanced age as the leading subpopulation.
The causative agents are non-steroidal anti-inflammatory agents and smoking. Males out number
females in the third world countries because s moking is the predominant factor here.

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Other factors include infection with Helicobacter pylori, long term steroid use, gastric
malignancies, trauma or corrosive ingestion. Upper gastroendoscopy induced iatrogenic
perforations are also one of the rarer causes.1,2
Morbidity is very common after peptic ulcer perforation, with rates ranging from 17% to 63%.
Pulmonary and wound infections are the most common postoperative infections. This is
especially true in older patients with coexisting pulmonary pathologies or smoking. 3

Diagnosis
Diagnosis in most of the cases is easily established on clinical examination. Patient may give a
history of ongoing treatment for peptic ulcer disease or history of upper abdominal discomfort or
reflux disease. Three clinical phases in the process of PPU can be distinguished 4
Phase 1: Chemical peritonitis/contamination. The perforation causes a chemical peritonitis. Acid
sterilizes the gastro-duodenal content; it is only when gastric acid is reduced by treatment or
disease (gastric cancer) that bacteria and fungi are present in the stomach and duodenum. At the
onset of perforation the patient has a severe upper central abdominal pain sometimes penetrating
to the back. The patient suddenly feels relieved of the pain as soon as the ulcer perforates.
Phase 2: Intermediate stage. After 6–12 h many patients obtain some relief of pain. This is probably due
to the dilution of the irritating gastro-duodenal contents by ensuing peritoneal exudates. This phase
can be misleading and delays diagnosis an also delays the patients arrival to the emergency set up.
Phase 3:Intra-abdominal infection. After 12–24 h intra-abdominal infection supervenes. The next
phase the patient starts to have increased abdominal distension, vomiting because of increased
paralytic ileus, sometimes fever and patients lies still in bed as changes in posture increases the
pain. This is the phase of bacterial peritonitis

Examination
Examination shows the patient to be dehydrated, with sunken eyes lying still in bed. In advanced
stages the patient may be mentally obtunded because of severe acidosis and hypoxia, the patient will
be having acidotic breathing pattern. Patient has tachycardia with low volume or feeble pulse
suggestive of shock or hypotension. The blood pressure recording will confirm the same. Abdominal
examination shows it to be distended along with board like rigidity, rebound tenderness and free fluid.
The bowel sounds are absent. The first site of pain is sometimes able to clinch the diagnosis.

Resuscitation and investigations

The patient is first resuscitated and only then sent for investigations like X-ray of the chest and abdomen.
Free air under the domes of diaphragm is conclusive of perforation peritonitis. Blood investigations might
show low hemoglobin, increased total leukocyte count. The blood urea and creatinine levels might be
increased and arterial blood gas analysis shows metabolic acidosis. Patients with features suggestive of
peritonitis but with no gas under diaphragm will warrant a contrast enhanced computer tomography.
In some situations especially where facilities of CECT are not available, pushing air through
nasogastric tube and getting a left lateral X-Ray of the abdomen may clinch the diagnosis.

Treatment:
Non operative management
Itis only advocated in patients who are too moribund to undergo any form of anesthesia or surgery. Here the
patient can be managed on intravenous fluids, nasogastric aspiration, antibiotics and percutaneous
intraperitoneal drain placement. Emergency surgery might be planned if the patient improves so much that it
is felt that he can withstand surgery. Very rarely the patient might recover fully on conservative management,
but these instances are so anecdotal that conservative management is not recommended. 3 Patients are
required to undergo gastro-duodenography wherein filling of duodenum, ulcer bed filling with contrast and
lack of spillage of contrast in peritoneal cavity has to be demonstrated to label the ulcer fully sealed.
Nowadays similar findings can be reported after contrast enhanced computer tomography. 3

Surgical management:
In 1929, Cellan Jones pioneered a technique where a pedicled omental patch was placed
over the duodenal perforation without repairing it primarily. This was modified by Roscoe
Reid Graham in 1937, where a free omental patch repair was done with good results. Both
of these techniques are followed and commonly performed procedure for peptic ulcer
perforation mainly duodenal and pre-pyloric ulcers.

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 Cellan Jones Technique Graham’s Patch
Indications of surgery:
The goal of any surgery for perforated duodenal ulcers is to provide durable repair of the injury
with appropriate control of the ulcer breach and limitation of parietal cell acid production.
Earlier goal used to be to decrease the acid production by simultaneous vagotomy and
drainage procedure.
The morbidity and mortality rates were high more so in advanced sepsis.
With the advent of first H2 inhibitors and subsequently proton pump inhibitors; the need for
surgical vagotomy has become almost obsolete.
The discovery of H pylori as a causative agent in duodenal ulcer and its eradication allowing
better cure rates was another factor for minimal surgical procedure.
Technique:
After laparotomy, the peritoneal cavity is thoroughly lavaged and then the perforation site is identified.

In Cellan Jones patch

In the original description of the technique, the full-thickness bites were placed approximately 0.5
cm away from the edges of the perforation from one margin to the other. A theoretical hazard with
the full-thickness bites is passing the needle through the posterior duodenal wall. Commonly,
three or four sutures are placed perpendicularly between the edges of the perforation and are laid
out on each side of the duodenum. Initial step of the repair with placement of sutures through the
wall defect left untied for securement of the omentum.
A pedicled patch of omentum is brought without tension and positioned over the perforation, and the sutures
are successively tied from the superior to the inferior aspect across the omental patch to anchor the graft in
place. This laid down a plug which was vascularised and allowed healing. This also prevented narrowing of
the first part of duodenum, which was a complication seen in earlier procedures.

Cellan Jones Repair. Inset(Final repair as seen from anterior with omentum secured in place on to
the defect itself)
This was modified by Graham’s where a free omental plug is placed in the perforation and secured with
sutures as described above. An important feature of a sturdy repair is reliant on the tying technique.
The applied tension to the sutures should be strong enough to stabilize the omentum in place but
loose enough to preserve the omental blood supply. Strangulation of the omental patch from increased
tension on the knots is associated with failure of the repair and continued postoperative leakage. In the
classical repair, the sutures are not passed through the omentum but only tied around it. Another
variation is to use sero-muscular sutures rather than full-thickness bites on the duodenum.

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With the advent of laparoscopy surgery in emergency cases, duodenal perforation repairs remain one
of the commonest procedures being done after emergency laparoscopic apendicectomies.
Laparoscopic repair has propagated a newer technique, wherein the duodenal perforation is first
primarily sutured with interrupted silk (the second technique in the above figure) and then a pedicled
omental flap is placed over the suture line.5 In skilled hands, laparoscopic repairs have reduced the
time of surgery and recovery rates. It has also reduced incidence of incisional hernia. But in unskilled
persons, the complications are high in form of leaks (because of poor suturing technique),
intrabdominal collections (because of inadequate lavage) and increased mortality also.5
Definitive surgery for perforated ulcer- can be performed if these conditions are fulfilled
If contamination of the upper abdomen is minimal
The patient is stable.
Duration of symptoms ideally should be less than 6hours.
Reasonable surgical expertise is available

highly selective vagotomy

truncal vagotomy and pyloroplasty
Vagotomy and antrectomy.
These definitive procedures take care of the etiological factors for peptic ulcer either the
increased acid production or the parietal layer area of the antrum. The recurrence rates after these
procedures are negligible. These procedures are time consuming and require reasonable degree
of expertise and should be attempted in a very selective group of patients. 6
The complication rates of surgery increases with the size of the perforation. Duodenal
perforations can be classified into three main groups (1) smallperforations that are less than 1 cm
in size, and have the best outcome; (2) largeperforations, that have a size between 1 cm and 3 cm;
and, (3) giantperforations that exceed 3 cm size.
Small and larger perforations to a large extent can be managed by omental patch repairs. Most
authors advocate repair with omental patch of perforations up to a size of around 2cm. Beyond
this size, repairs with this technique is not deemed safe. Some authors only consider giant
perforations in this category. Over the years various authors have recommended repairs based on
their experiences. These have included
Resection of the perforation bearing duodenum and the gastric antrum in the form of a partial
gastrectomy, with reconstruction as either a Billroth I or II anastomosis. 6
procedure of gastric disconnection in which vagectomy, antrectomy, gastrostomy, lateral
duodenostomy and feeding jejunostomy are performed, with restoration of intestinal
continuity electively after 4 weeks of discharge.7
Others have recommended conversion of the perforation into a pyloroplasty, along with
vagotomy. 8
Closure of the perforation using a serosal patch (Thal Patch in the picture below) or a pedicled
graft of the jejunum.

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 The use of a free omental plug to patch the defect, and even, suturing of the omentum to
the nasogastric tube. 9
Proximal gastrojejunostomy and / or vagotomy may be added to these procedures to
provide diversion and a definitive acid reducing procedure respectively.10
Another difficult area is management following leak of omental patch repairs of duodenal perforations.
The options available are:
In both stable & unstable patients reinforcement of the original omentoplasty, if feasible
Additional options for stable patient include- wide drainage + feeding jejunostomy
or a definitive procedure as described above.11
Additional options for unstable patient include- wide drainage + feeding
jejunostomy or pyloric exclusion with gastroenterostomy
If reinforcement of the original omentoplasty not feasible - ulcer intubation or
jejunal serosal patch.12
Rectus abdominis vertical flap can be used as a salvage technique to close the
leak site.13
Bibliography:
Zelickson MS, Bronder CM, Johnson BL, Camunas JA, Smith DE, Rawlinson D, et al: Helicobacter pylori is not the
predominant etiology for peptic ulcers requiring operation. Am Surg. 2011, 77: 1054-60.
Svanes C: Trends in perforated peptic ulcer: incidence, etiology, treatment, and prognosis. World J Surg. 2000, 24: 277-83.
Feng Cao,Jia Li, Ang Li,Yu Fang,Ya-jun Wang, Fei Li. Nonoperative management for perforated peptic ulcer: Who can
benefit? Asian J of Surg.2014;37:148-53.
Schein M: Perforated peptic ulcer; in (ed.): Schein’s Common Sense Emergency Abdominal Surgery. Part III. Berlin,
Springer, 2005, pp 143–50.
Lau WY: Perforated peptic ulcer: open versus laparoscopic repair. Asian J Surg 2002;25:267–9.
So JB, Yam A, Cheah WK, Kum CK, Goh PM: Risk factors related to operative mortality and morbidity in patients undergoing
emergency gastrectomy. Br J Surg. 2000, 87: 1702-7.
Cranford CA, Olson RO, Bradley EL: Gastric Disconnection in the Management of Perforated Giant Duodenal Ulcer. Am J
Surg. 1988, 155: 439-42.
Chaudhary A, Bose SM, Gupta NM, Wig JD, Khanna SK: Giant Perforations of Duodenal Ulcer. Ind J Gastroenterol.
1991, 10: 14-5.
Karanjia ND, Shanahan DJ, Knight MJ: Omental patching of a large perforated duodenal ulcer: a new method. Br J Surg. 1993,
65.
McIlrath DC, Larson RH: Surgical management of Large Perforations of the Duodenum. Surg Clin North Am. 1971, 51: 857-61.
Sharma D, Saxena A, Rahman H, Raina VK, Kapoor JP: 'Free Omental Plug': A Nostalgic Look at an Old and Dependable
Technique for Giant Peptic Perforations. Dig Surg. 2000, 17: 216-8.
Jani K, Saxena AK: Management of Large Sized Duodenal Peptic Perforations by Omental Plugging – A New Technique: A
Prospective Randomised Study of 100 patients. Ind J Surg. 2000, 62: 134-8.
Chander J, Lal P, Ramteke V K. Rectus abdominis muscle flap for high output duodenal fistula- a novel technique.
World J Surg 2004; 28: 179.

CROHN’S DISEASE
-Dr Nikhil Talwar

The two major forms of Inflammatory Bowel Disease (IBD) are Crohn’s disease (CD) and ulcerative colitis
(UC). The term indeterminate colitis is often used where an apparently idiopathic colitis demonstrates
features consistent with both Crohn’s disease and ulcerative colitis. In his memoir, Dr. Burrill Crohn recalls
being told by his medical school professor that “there are no recognizable diseases of the small intestine
except, perhaps, tuberculosis”. He encountered his first case of “regional ileitis” in a 17-year-old boy who
presented with diarrhea, fever, and a palpable mass in the right lower abdomen.
Crohn’s disease (CD) encompasses a multisystem group of disorders with specific clinical and pathological
features characterized by focal, asymmetric, transmural, and, occasionally, granulomatous inflammation
primarily affecting the gastrointestinal (GI) tract. It is a multisystem disorder with potential for systemic and
extra-intestinal complications that can affect any age group, but the onset is most common in the second
and third decades. It is important to differentiate CD from other inflammatory diseases of the gut that can
simulate or complicate its clinical course. CD is a chronic inflammatory disorder that is neither medically nor
surgically “curable” requiring therapeutic approaches to induce and maintain symptomatic control, improve
quality of life, and minimize short- and long-term toxicity and complications. Newer goals of therapy include
the induction and maintenance of mucosal healing that are beginning to translate into changing the “natural
history” of CD.

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CAUSES:
Genetic factors
Studies have pointed to a genetic predisposition in a subset of IBD patients, specifically CD. The
disease is more common in Ashkenazi Jews and second‐generation Asians in developed
countries. In excess of 160 different IBD associated genes have been demonstrated and generally
more than one genetic association is needed to produce disease in an individual.
Environmental factors
The greatest prevalence of IBD is in developed countries, specifically where there is improved
sanitation. It has been hypothesized that exposure to unhygienic conditions in early years can result in
the development of intestinal immune defense mechanisms. Dietary influences on the epidemiology of
IBD are evident, in particular the move from a diet based on oily fish to animal fat in some societies and
an associated increase in IBD incidence. Smoking is another important factor, and curiously has
contrasting effects in CD and UC: increasing the risk of relapse in Crohn’s and reducing the risk in UC.
Immunological factors
Recent evidence points to the role of the host bacterial environment in exerting a protective or
stimulatory effect on the mucosal inflammation in IBD. This bacterial profile depends on early‐life
factors (breast feeding, sanitation). Debate continues as to whether a single pathological agent
might be responsible for causation in some individuals or whether it is interactions between the
organisms that make up the intestinal microbiota that are important.
Pathogenesis
The gut tissue damage results from the interplay of circulating and gut immune cells (lymphocytes and
neutrophils) and non‐immune cells (mast cells and fibroblasts). It is clear that dietary antigens and host
bacteria play a key initiating role in this inflammatory process. The antigens are taken up through breaches
in the mucosa and specialized antigen‐presenting cells (APCs) liberate a variety of pro‐inflammatory
cytokines, such as tumour necrosis factor‐α (TNF‐α) and interleukin‐12 (IL‐12). These APCs pass on the
antigen to CD4+ T‐lymphocytes, which themselves then differentiate down specific pathways.The net result
is recruitment of further inflammatory cells (through increased adhesion of neutrophils to vascular
endothelium) and activation of non‐immune cells (mast cells, fibroblasts). This in turn results in tissue
damage and hence further ingress of antigen from the lumen into the gut mucosa.
Finally, in predisposed individuals, this inflammatory process can extend beyond the gut,
resulting in the extra-intestinal features of IBD.
Epidemiology
The incidence of Crohn’s disease, which is increasing, is approximately 7 in 100,000 in the
developed world, with a prevalence of approximately 70 in 100,000. There is marked geographical
variation, with New Zealand having one of the highest reported incidences in the world.
Indian perspective
IBD has traditionally been thought to be uncommon in India. Initial reports of CD in India included
those of a few surgically treated patients who had presented with predominantly ileo-cecal structuring
disease. Despite this, doubts persisted as to whether this was true CD in view of the widespread
endemicity of intestinal tuberculosis in India, so much so, that a diagnosis of CD was met with
derision. However, in the past few years there has been a growing realization that, despite the high
prevalence of intestinal tuberculosis, CD does occur in India. This has been attributed to increasing
awareness and availability of diagnostic facilities, coupled with improved sanitation, as is being seen in
the rest of Asia. Differentiating factors between CD and intestinal tuberculosis are listed in table 1.

Clinical features
Crohn’s disease is characterized by abdominal pain and diarrhea, but specific symptoms depend
on the region of gut involved. Because of variability of severity and location of CD, as well as its
transmural nature, patients can have wide-ranging presentations.
Distribution of disease
Although it can be difficult to differentiate Crohn’s disease from ulcerative colitis, there are
important differences in the distribution of the diseases. As well as the severity and nature of the
disease (i.e. inflammatory vs structuring), the distribution of disease has a large influence on what
symptoms are exhibited. Crohn’s disease affects the gut in a non‐continuous way, causing
characteristic ‘skip’ lesions with normal mucosa in between. Involvement is ileal or ileocolonic
(40%), small intestinal (30%), purely colonic (20%) and purely perianal (10%). In children, proximal
gut inflammation is more common. Inflammation involves the full thickness of the gut wall with
deep ulcers, causing a ‘cobblestone’ appearance.

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Ulcers may be so deep as to penetrate the bowel wall, causing fistulae and abscesses. The
fistulae may be from the gut to adjacent viscera (bladder, vagina, other regions of the gut) or
through the skin. The histological hallmark is of giant cell granuloma.

Ileal Crohn’s: may cause small bowel obstruction and an inflammatory mass or abscess, resulting
in abdominal pain (commonly post‐prandial). This results in anorexia coupled with non‐bloody
diarrhoea. Weight loss is common. Inflammation of the small intestine may cause malabsorption,
resulting in anaemia (classically B12 or folate deficiency) or malnutrition. About 30% of patients
with CD have inflammation confined to the small bowel. At least 60% of the patients having at
least some ileal involvement.

Proximal intestinal Crohn’s disease: is more often associated with vomiting.

Crohn’s colitis: presents with bloody diarrhoea, loss of mucus and constitutional symptoms
(malaise and fever). In contrast to ulcerative colitis, which has similar symptoms, there is typically
‘rectal sparing’ on sigmoidoscopy. About 20% of patients have isolated colonic involvement.

Perianal Crohn’s: manifests in about 25% of patients with Crohn’s disease, and may include
perianal fissure, fistulae, and anal ulceration and strictures. Perianal Crohn’s disease is usually
associated with inflammation in the distal colon or in the small bowel.

Perianal Crohn’s can be classified into non fistulizing manifestations and fistulizing disease.
Non fistulizing perianal manifestations include anal fissures, skin tags, anal ulceration, and
strictures. The prevalence of fistulizing Crohn’s disease is about 21% in population-based studies,
and as high as 43% in referral centers. Anal fistulae can arise de novo, or after radiation, anorectal
tuberculosis, or malignancy involving the anus or rectum, including squamous cell cancer,
adenocarcinoma, and lymphoma. The prevalence of anal fissures among patients with Crohn’s
disease has been reported to be as high as 35%.
Extra intestinal disease
About 35% of patients develop extra intestinal manifestations of IBD, and some (but not all) of
these relate to the activity of disease in the gut. HLA‐B27 positivity predisposes to joint
manifestations. Axil and peripheral arthropathies are the most common extra intestinal
manifestations, but uveitis, episcleritis, pyoderma gangrenosum, erythema nodosum, and primary
sclerosing cholangitis are all associated with IBD.
Investigations
The diagnosis of CD is usually established from clinical findings and relies on a good history and
physical examination. No laboratory tests specifically establish a CD diagnosis. Investigations are
directed towards confirming the condition (i.e. diagnosis, defining extent of disease and activity of
disease), and assessing for complications.
Endoscopy
Colonoscopy with ileal intubation is generally required for the assessment of Crohn’s disease,
and should include biopsies for histopathology assessment to exclude infection and lymphoma,
and corroborate the severity of inflammation. Sigmoidoscopy will identify an inflamed rectum in
active ulcerative colitis (but may be normal in Crohn’s colitis).
In particular, the index or initial colonoscopy provides important information about anatomic extent of
involvement, as these findings are unlikely to have been influenced by medical therapy. Endoscopy of
the upper or lower tract for Crohn’s disease also offers the opportunity for therapeutic balloon dilation
of strictures. Colonoscopic findings include various manifestations of inflammation, including
erythema, erosions, ulceration, and stricturing. Ulcers are characterized morphologically as aphthous,
linear, or stellate. If a stricture is encountered, the length of the stricture should be reported, and
biopsies should be obtained to exclude malignancy. Short stenosis and anastomotic strictures (less
than 4cm) may be amenable to endoscopic balloon dilatation.
There are several instruments that have been developed for clinical trials to score Crohn’s endoscopic
disease activity. The most commonly used indices include the Crohn’s Disease Endoscopic Index of
Severity (CDEIS) and the Simple Endoscopic Score (SES), which score the presence, size, and extent of
ulceration and inflammation in the ileum and individual colonic segments. In patients who have had an
ileocolonic resection, the Rutgeerts score should be used to grade the anastomosis for endoscopic
recurrence, in order to determine the prognosis for clinical recurrence and need for therapy.

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 Table 1: Differentiation of Crohn’s disease (CD) from intestinal tubercul osis (IT)

Capsule endoscopy is a relatively new technology that has been found to be useful fo r the evaluation
of patients with occult or obscure gastrointestinal bleeding in cases where colonoscopy and upper
endoscopy are non-diagnostic. Cap sule endoscopy can identify small bowel Crohn’s d isease with a
high degree of accuracy. But it carries a n increased risk of capsule retention in CD.
Histology
At the time of endoscopic evaluation, biopsies for histopathological evaluation can be helpful to establish
the diagnosis. Non caseating gran ulomata are considered pathognomonic for Croh n’s disease in this
setting, although they are only seen in about 15% of patients. Histological findings of ch ronic inflammation
include lymphoid aggregates, mix ed acute and chronic inflammatory infiltrates with lymphocytes and
neutrophils, crypt abscesses, neuronal hypertrophy, Paneth cell metaplasia, and others.
Abdominal X‐ray
In Crohn’s ileitis plain X-ray of the abdomen may show small bowel obstruction.
Small bowel studies
Fluoroscopic studies using intestinal contrast like Barium Meal Follow through h ave largely been
supplanted by cross‐sectional stu dies. Another advantage to cross-sectional imagi ng over traditional
barium small bowel series is the ability to incidentally assess for and evaluate extra intestinal
manifestations, including sacroileitis, pancreaticobiliary involvement, lower lung abnormalities, ovarian
pathology (which may confound cli nical evaluation of the right lower quadrant), obstruc tive uropathy,
and nephrolithiasis. Intravenous contrast is also administered during these studies, in order to identify
areas of mucosal hyper enhancement that is suggestive of active inflammation.

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Computed Tomography (CT) has the advantage of being quick and is often more accessible than
Magnetic Resonance Imaging (MRI). MRI has the advantage of not using ionizing radiation, and thus
being more appropriate in young patients who may require repeated scans over time. The small bowel
is distended by fluid, usually administered orally. These are not often required in the acute situation,
but do have a role in defining the extent of disease. Typical findings of active inflammation using
enterography protocols include the “comb sign”, which refers to engorgement of the vasa recta, and
the “target sign,” which refers to the trilaminar enhancement of the layers of the bowel wall including
enhancing mucosa (bright), submucosal edema (dark), and enhancing serosa (bright).

Management
Different approaches are needed when attempting to induce remission of disease compared to
maintaining remission once induced (see Table 2). Because of their speed of onset, corticosteroid
may be appropriate to help induce remission and act as a bridge to a longer‐term
immunosuppressive strategy, but their side‐effect profile and lack of long‐term efficacy make
them inappropriate as a maintenance therapy.

Medications for IBD

The therapeutic approach to different forms and severities of IBD are outlined later in this chapter. This
section briefly considers the medicines commonly used in IBD, their mechanism and risks. The order used
here is the same as the order in which they would often (but not always) be used in clinical practice.

Table 2: Therapies used to induce remission vs. maintain remission.

Remission induction Remission maintenance
Corticosteroids 5‐aminosalicylates (5ASA)
Cyclosporin Azathioprine/6‐mercaptopurine
Anti‐TNF‐alpha antibodies Methotrexate
Surgery Anti‐TNF‐alpha antibodies
Lifestyle (cessation of smoking)

5‐aminosalicylic acid preparations (5ASA)

These agents can be considered ‘ointment for the bowel’. They act as topical anti‐inflammatory and
can be administered either orally or rectally. Combining oral and rectal therapy is the most effective
strategy for inducing remission. Because of their topical action when taken orally, they need to be
released in the inflamed area. The main limiting adverse effects include nausea, diarrhoea (rarely 5ASA
induced colonic inflammation), skin rashes and headaches. Dose‐dependent nephritis occurs in up to
1 in 1000 patients and most experts recommend monitoring for renal dysfunction by monitoring
creatinine. Adherence to 5ASA treatment is poor, at least in part because the tablet burden is high.
Using the medicine once per day improves this. Although high-quality evidence supporting use of 5-
aminosaliclylates in UC, this is not the case for CD.

Antibiotics
Antibiotics are often used to decrease the intraluminal bacterial load in Crohn’s disease.
Metronidazole has been reported to improve Crohn’s colitis and perianal disease, but the
evidence is weak. Fluoroquinolones may also be effective in some cases. In the absence of
fulminant colitis or toxic megacolon, antibiotics are not used to treat ulcerative colitis.

Corticosteroids
Systematically acting corticosteroids have been the mainstay therapy for CD. They very effectively
induce remission of moderate to severe disease. These drugs do not maintain remission. The oral
preparation used is generally prednisolone and hydrocortisone is the most frequent intravenous
preparation used in hospitalized patients with severe disease. A commonly used regimen in IBD is 40
to 60 mg of prednisolone, reduced by 5 mg every 1 to 2 weeks as tolerated. Corticosteroids are poorly
tolerated by many patients and have extensive side‐effects, including weight gain, skin changes,
dysphoria, glaucoma/ cataracts, hypertension, and predisposition to infection, diabetes and
osteoporosis. The latter is one of the more feared consequences of long‐term corticosteroid use and
should be monitored for carefully and treated appropriately.

Budesonide is a steroid that exhibits limited absorption in the gut and enteric-coated budesonide
is an alternative to conventional steroids in patients with ileal and right-sided colonic CD.

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Because of its substantial first-pass metabolism in the liver, budesonide is associated with less
toxicity than systematically absorbed steroids.
Once steroids are given to a patient with moderate to severe CD, the next goal is to maintain
steroid-free remission. This typically entails use of an immunomodulators or biologics.

Immunomodulators
Immunomodulators, thiopurines (azathioprine, mercaptopurine), and methotrexate are used primarily for the
maintenance of remission in patients with moderate to severe or steroid dependent CD. Although these
drugs nay induce remission, they are suboptimal because of their slow onset of action. Typically,
immunomodulators must be used together with a more rapid-onset medication. Adverse effects associated
with immunomodulators include increased risk of infection, bone marrow suppression and liver toxicity.
There is a 4- to 5-fold increased risk of Non-Hodgkin Lymphoma with thiopurines in this patient population.
Patients taking immunomodulators require continual surveillance for complications.

Biologics
Monoclonal antibodies directed against TNF-α effectively induce and maintain remission in patients
with moderate to severe CD. Anti-TNFs are also effective for the treatment of perianal fistulas. The
three common ant-TNFs available for the treatment of CD are: infliximab, adalimumab, and
certolizumabpegol. These treatments are not orally bioavailable and must be given parenterally,
generally by 8‐weekly infusion in the case of infliximab and fortnightly subcutaneous injection for
adalimumab. They are prone to the effect of neutralising antibodies produced by the recipient over time
and are often used with another immunosuppressant, typically azathioprine, to counter this effect.

Treatment protocol for Crohn’s Disease

Inducing remission
Localised terminal ileal or ileo‐caecal disease:
Medical first line: course of oral prednisolone (>40 mg reducing over 4−6 weeks) or
budesonide (a less well‐absorbed steroid, hence causing fewer side‐effects). In mild
disease high‐dose 5ASA can be considered as a first‐line therapy.
Medical second line: infliximab/adalimumab –these are monoclonal antibodies targeting
TNF‐α that can induce rapid healing.
Surgical: limited ileal resection (may be preferredby patients as first‐line therapy, and should be
considered in all patients if frequent relapses occur; patients will need B12replacement long term).

First line: prednisolone or budesonide.

Second line: infliximab/adalimumab.
Third line: enteral nutrition using polymeric formula.
Colonic disease:
Proctitis or left‐sided colitis – determine severity:
Mild: 5‐ASA or prednisolone suppositories for proctitis, enemas for left‐sided disease.
Severe: 5‐ASA or prednisolone enemas; if refractory, course of oral
prednisolone. Extensive colitis – determine severity:
Mild: high‐dose oral 5‐ASA and 5‐ASA enemas;
Severe: course of oral prednisolone.

Fissure: topical gliceryltrinitrate and/or 5‐ASA or prednisolone suppository.

Fistula: oral metronidazole and perianal MRI; if complex (multiple fistulae or abscess
formation) for EUA and non‐cutting seton suture. Once sepsis controlled, treat with
infliximab +/− azathioprine/6MP.
Abscess: surgical or radiologically guided drainage

With mild disease treatment may be able to be stopped, but if relapses occur despite continuous
high‐dose oral 5‐ASA, treatment is as for moderate‐severe disease and more extensive disease.

First line: azathioprine/6MP.

Second line: methotrexate, particularly for steroid‐dependent disease.
Third line: anti‐TNF therapy.

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Perianal disease:
If frequent relapses or severe inflammation occur, then treat with infliximab +/− azathioprine/6MP.

Surgery
Because Crohn’s disease can affect any part of the gastrointestinal tract, the therapeutic rationale is
fundamentally different from that of ulcerative colitis. Ulcerative colitis may be cured by removal of the
affected intestinal segment (the colon and rectum). In Crohn’s disease, it is impossible to remove the
entire at-risk intestine; therefore, surgical therapy is reserved for complications of the disease.
Crohn’s disease may present as an acute inflammatory process or as a chronic fibrotic process. During the
acute inflammatory phase, patients may present with intestinal inflammation complicated by fistulae and/or
intra-abdominal abscesses. Maximal medical therapy should be instituted, including anti-inflammatory
medications, bowel rest and antibiotics. Parenteral nutrition should be considered if the patient is
malnourished. Most intra-abdominal abscesses can be drained percutaneously with the use of CT scan
guidance. Chronic fibrosis may result in strictures in any part of the gastrointestinal tract. Because the
fibrotic process is gradual, free perforation proximal to the obstructing stricture is rare. Chronic strictures
almost never improve with medical therapy. Optimal timing for surgery should take into account the patient’s
underlying medical and nutritional status. Strictures may be treated with resection or stricturoplasty. Distal
ileal strictures are sometimes amenable to colonoscopic balloon dilatation.
Once an operation is undertaken for Crohn’s disease, several principles should guide
intraoperative decision making. In general, a laparotomy for Crohn’s disease should be performed
through a midline incision because of the possible need for a stoma. Laparoscopy is also
increasingly used in this setting. Because many patients with Crohn’s disease often will require
multiple operations, the length of bowel removed should be minimized. Bowel should be resected
to an area with grossly normal margins; frozen sections are not necessary. Finally, a primary
anastomosis may be created safely if the patient is medically stable, nutritionally replete, and
taking few immunosuppressive medications. Creation of a stoma should be strongly considered
in any patient who is hemodynamically unstable, septic, malnourished or receiving high-dose
immunosuppressive therapy and among patients with extensive intra-abdominal contamination.

Ileocolic and Small Bowel Crohn’s Disease.

The most common indications for surgery are internal fistula or abscess (30%–38% of patients) and
obstruction (35%–37% of patients). Psoas abscess may result from ileocolic Crohn’s disease. Sepsis
should be controlled with percutaneous drainage of abscess(es) and antibiotics, if possible. Parenteral
nutrition may be necessary in patients with chronic obstruction. The extent of resection depends on
the amount of involved intestine. Short segments of inflamed small intestine and right colon should be
resected and a primary anastomosis created if the patient is stable, nutrition is adequate, and
immunosuppression is minimal. Isolated chronic strictures should also be resected. In patients with
multiple fibrotic strictures that would require extensive small bowel resection, stricturoplasty is a safe
and effective alternative to resection. Short strictures are amenable to a transverse stricturoplasty,
while longer strictures may be treated with a side-to-side small bowel anastomosis.

Crohn’s Colitis
Crohn’s disease of the large intestine may present as fulminant colitis or toxic megacolon.
Resuscitation and medical therapy with bowel rest, broad-spectrum antibiotics, and parenteral
corticosteroids should be instituted. If the patient’s condition worsens or fails to rapidly improve, total
abdominal colectomy with end ileostomy is recommended. An elective proctectomy may be required if
the patient has refractory Crohn’s proctitis. Alternatively, if the rectum is spared, an ileo-rectal
anastomosis may be appropriate once the patient has recovered. Other indications for surgery in
chronic Crohn’s colitis are intractability, complications of medical therapy, and risk of or development
of malignancy. Annual surveillance colonoscopy with multiple biopsies is recommended for patients
with longstanding Crohn’s colitis (>7 years in duration). As in ulcerative colitis, dysplasia is an
indication for total proctocolectomy. Ileal pouch– anal reconstruction is not recommended in these
patients because of the risk for development of Crohn’s disease within the pouch and the high risk of
complications, such as fistula, abscess, stricture, pouch dysfunction, and pouch failure.

Anal and Perianal Crohn’s Disease

Treatment of anal and perianal Crohn’s disease focuses on alleviation of symptoms. Perianal skin
irritation from diarrhea often responds to medical therapy directed at small bowel or colonic disease.

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In general, skin tags and hemorrhoids should not be excised unless they are extremely symptomatic
because of the risk of creating chronic, non healing wounds. Anal fissures can be treated medically,
with seitz baths and topically applied 0.4% nitroglycerin ointment or 2% diltiazem cream. Surgical
removal of skin tags in patients with Crohn’s disease is generally not recommended due to risks of
poor wound healing. Anal ulcers can occur with a reported prevalence of up to 10%. Treatment of anal
ulcerations may warrant anti-TNF therapy, with retrospective data demonstrating a 72% long-term
response rate. Sphincterotomy is relatively contraindicated because of the risk of creating a chronic,
non healing wound and because of the increased risk of incontinence in a patient with diarrhea from
underlying colitis or small bowel disease.

Recurrent abscess(es) or complex anal fistulae should raise the possibility of Crohn’s disease.
Treatment focuses on control of infection, delineation of complex anatomy, treatment of
underlying mucosal disease, and sphincter preservation. Abscesses often can be drained locally,
and mushroom catheters are useful for maintaining drainage. Endoanal ultrasound and pelvic MRI
are useful for mapping complex fistulous tracts. Liberal use of setons can control many fistulas
and avoid division of the sphincter. Endoanal advancement flaps may be considered for definitive
therapy if the rectal mucosa is uninvolved but will not heal due to rectal inflammation. In 10% to
15% of cases, intractable perianal sepsis requires proctectomy.

Rectovaginal fistula can be a particularly difficult problem in these patients. A rectal or vaginal mucosal
advancement flap may be used if the rectal mucosa appears healthy and scarring of the rectovaginal
septum is minimal. Occasionally, proctectomy is the best option for women with highly symptomatic
rectovaginal fistulae. Although proximal diversion is often employed to protect complex perianal
reconstruction, there is no evidence that diversion alone increases healing of anal and perianal
Crohn’s disease. Medical treatment of underlying proctitis with salicylate and/or corticosteroid enemas
may be helpful; however, control of infection is the primary goal of therapy. Metronidazole has been
used with some success in this setting. Anti-TNF-α agents (infliximab and adalimumab) have shown
some efficacy in healing chronic fistulas secondary to Crohn’s disease.

Future Management of Crohn’s Disease

The management of CD is rapidly changing. A number of promising drugs are in development that
will cause treatment approaches to evolve further. These include Ustekinumab (a monoclonal
antibody to the p40 subunit, which blocks the effect of IL‐12/23 and has effect against IBD),
natalizumab (an antibody to alpha‐4 integrin), vedolizumab (which acts on alpha‐4 beta‐7
integrin), etrolizumab (which targets the beta‐7 integrin subunit) and tofacitinib (an oral Janus
Kinase [JAK] inhibitor). Hopefully, the research on the genetics of CD and the human microbiome
will help uncover the cause of CD and result in new treatment options and prevention strategies.

ROBOT ASSISTED BARIATRIC SURGERY

-Dr. VivekBindal

INTRODUCTION
With the rise in the prevalence of obesity, which is now a worldwide problem, the field of bariatric
surgery is witnessing an ever increasing demand. Estimated number of procedures performed in
US alone is shown in table 1.
Performing bariatric surgery can be technically demanding in many situations because of large
patients with high body mass index (BMI), large livers, thick abdominal walls and substantial visceral
fat making exposure, dissection, and reconstruction difficult. 1The super obese (SO) patients with a BMI
≥50 kg/m2is a difficult to manage population because of limited working space, excessive torque on
instruments due to thick abdominal wall, co-morbidities and high-risk anaesthesia.2the management of
patients with super-super obesity (bmi >60 kg/m2) also remains a challenge.3Moreover, the surgeons
encounter very difficult ergonomic positions, which can potentially be very distressing and career
shortening for them. The surgeons have been looking for methods to improve the patient outcomes,
surgical technique, size of incisions and decrease complications on one hand, and also which is
ergonomically favorable.Intuitive Surgical, Inc., United States of America obtained Food and Drug
Administration approval in 2000 and introduced the da vincitm robot system in the United States
providing an alternative platform for performing minimally invasive surgery.

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It has been used for complex ab dominal operations including bariatric procedures namely
adjustable gastric band, sleeve gastrectomy, Roux-en-Y gastric bypass, biliopancreatic diversi on
with or without duodenal switch and revisional bari atric procedures.
Robotics in bariatric surgery has been evolving since Cadiereet al. reported the first such case in
1999.4Robotic platform has given the advantages of three-dimensional vision, incre sed dexterity
and precision by downscaling surgeo n’s movements enabling a fine tissue dissection and
filtering out physiological tremor.5,6 It overcomes the restraint of torque on ports from thick
abdominal wall, and minimizes port site trauma by remote center technology7The main limitation
with robotic surgery is the perceived higher cost and set-up time compared with laparoscopy. But
with increased experience, it is seen that set-up times reduce, an d costs may also come down as
material prices reduce and other players comes into the market.8

Table 1. ASMBS estimated total bariatric procedures.

Setting up the operating room fo r robotic bariatric surgeries

Inspite of technical differences in h ow each of the bariatric operations are performed, setting up
of the operating room similar for all roboti c bariatric operations (Fig. 1) This setup can be ada
pted based on the space considerations of other opera ting rooms.
The instrument table is set up on the patient’s right side. The video monitor and r obot tower is also
positioned on the right and more towards the head of the patient. The anaesthesia cart is to the
patient’s left side. The surgeon’s console is positioned on the right side of the patient in the farthest
corner of the room allowing for direct communica tion with the scrub assistant and also within easy v
iewing distance of the console surgeon. The robot is docked over the patient’s head, either head on or
parallel docking ensuring that the robot arms have adequate clearance from the operating room table
or the patient. Target anatomy, camera port an d central column all lie in the same plane. Slig ht
variation in the orientation of the robot may be required depending on the specific bariatric operation.
Each of the robot-assisted bariatric operations will ne xt be discussed individually.

Robotic Roux-en-Y Gastric Bypa ss

It is the most studied robotic bariatric procedure and is still considered as the gold standard surgical
procedure for morbid obesity by m any specialists 9.10The overall results are good in terms of both weight
loss and comorbidity resolution 11

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RYGB involves two anastomoses (gastrojejunostomy [GJ] and Jejunojejunostomy). Hand sewn
anastomosis is proven to be having fewer complications as compared to stapled one, robotic
surgery is currently considered as an attractive technology that could help perform RYGB, given
its well-described advantages12.

Our (iMAS) technique

The technique of choice at our Centre (iMAS) is Totally Robotic RYGB with a hand-sewn
gastrojejunostomy. The instrumentation and technique are described below.
Instrumentation
ROBOTIC INSTRUMENTS (da Vinci® Si system (Intuitive Surgical, Sunnyvale, CA):
1. R1- Ultrasonic shears– 5 mm.
Large needle driver- 8 mm.
Monopolar hook- 8mm.
2. R2- Cadiere forceps- 8 mm.
3. R3- Double fenestrated grasper 8 mm.
POSITION:
Position the patient supine position with left arm by the side and 20° of reverse Trendelenburg
position with padding under both knees. Place a Foley catheter (optional) and secure the feet with
tape and padding to the footboard. Place a safety strap just above the patient’s knees. 
The
abdomen is cleaned and draped, and a Gastric bougie of 38 FR with a Ryle’s tube inside placed in
stomach. The assistant surgeon stands by the side of the patient with scrub nurse. The
anesthesia machine is kept on one side of the head end, as the patient cart comes in from the
head end. C. PORT PLACEMENT: (Fig 2)

Pneumoperitoneum created at palmer’s point using veress needle (closed technique).

Using optical trocar, entry made at camera port. All other ports placed under vision to avoid any
inadvertent injury.
All the ports are marked after insufflation as port position shifts significantly after insufflation.
C Camera port, placed 20 cm from Xiphisternum slightly to the left of midline.
R2 In right mid-clavicularline ,20 cm from Xiphisternum in arc like fashion.
A (Assistant Port) Between port C and port R2 at least 8 cm apart.
R1 in left mid clavicularline ,20 Cm from xiphisternum.
R3 in left anterior axillary line at the level of camera port.
A 5-mm epigastric port is used to place a Nathanson liver retractor to retract the left lobe of
the liver. D. Technique
Diagnostic laparoscopy and Bowel Marking
Diagnostic laparoscopy done. Nathanson’s liver retractor placed. Assistant Surgeon stands on the right side
of patient. Omentum lifted upwards from left horizon & ligament of Trietz identified. Bowel walked 75 cm
distal to ligament of Trietz, keeping proximal loop (biliopancreatic limb) on left side of patient, bowel hitched
to stomach near lesser curvature at two sites using non absorbable suture (fig 3).

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Bowel walking continued from 1st mark, 100 cm distally & marked using non-absorbable suture at
two sites 5 cm apart keeping proximal stitch small and distal stitch large.

Robot Docking
Robot docked in from head end. The master console is placed so that the surgeon can freely
visualize the operative field while sitting on the console. Patient cart brought in from head end.
Patient’s cart central column, target anatomy (stomach)and camera port, all lie in single straight
line.Two video monitors are placed on either side of the patient to enable the assistants to easily
watch and help at every step of procedure, with ergonomic comfort

Operative room set-up (Fig 4)

Gastric pouch formation

Taking following instruments in three arms, dissection is started.
R1- Harmonic 5 mm long
R2- cadiere forceps.
R3- Double fenestrated grasper.
Dissection started by taking down the Phrenoesophageal membrane, using energy source (monopolar hook
or ultrasonic shears), after retracting the fundus of the stomach caudally. Using peri-gastric dissection a
small gastric pouch of capacity 20-30 ml is created starting between the first and second vessel from the
gastroesophageal junction. R3 is used to retract the stomach laterally, while the Harmonic scalpel in R1 is
used to open up the gastrohepatic ligament. Perigastric dissection is commenced using the harmonic
shears/hook, avoiding injury to the vagus nerve, and the lesser sac is reached (Fig. 5,6).

A horizontal fire of the stapler is done by the assistant surgeon using a 60-mm blue/tan cartridge.
(Fig 7,8).

Dissection is continued superiorly to free the posterior adhesions of the stomach. Bougie is
placed at this time to size the pouch. The vertical firing is done (60-mm blue/purple cartridge, two
usually needed), and pouch creation is completed (Fig.9).

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Gastro-jejunal anastomosis
Using barbed suture, imbrication of vertical limb of gastric pouch is continued as fourth layer of
Gastro-Jejunostomy. (Fig 10)
Gastrostomy & Enterotomy made using Monopolar hook / harmonic shears and stoma widened
using harmonic shears in R2 creating a stoma length of 2-2.5 cm approximately.(Fig 11.)
Using a new barbed suture, third layer (posteriorly) started from left side, towards right side
.Same suture reversed at opposite end(right)to form 2nd layer of anastomosis (anteriorly).
Anterior- most layer completed using another barbed suture thus completing the anastomosis. (Fig 12).

Jejuno-jejunal anastomosis
Window created in Jejunum mesentery just proximal to Gastro-jejunostomy (towards left side)
and jejunum transacted using white / tan- 60 mm cartridge thus creating a biliopancreatic limb of
75 cm.(Fig 13).
Roux limb measured for 100 cm from Gastro-jejunostomytill we reach the previously placed
marking sutures.Enterotomies made at 100 cm mark and in the biliopancreatic limb. Jejuno-
jejunostomy (side to side) made using blue / tan 60 mm cartridge).(Fig 14,15).

Enterotomy closed in single layer using non- absorbable from below upwards in continuous
fashion.(Fig 16)

Closure of Mesenteric defects

Mesenteric defect (defect between small bowel mesenteries) closed using non -absorbable suture
2-0 below upwards.Peterson defect (defect between the small bowel limb and transverse
mesocolon) examined and closed using continuous non -absorbable suture.
Intra-operative leak test done using Upper GI Endoscopy / methylene blueto rule out any
intraluminal bleeding or leak. A Jackson -prattdrainis placed which is removed after 48 hrs.

Literature review
There have been nine significant published series comparing outcomes of RRYGB versus laparoscopic
RYGB (LRYGB). 13-21 These studies represent the entire literature on RRYGB and its outcomes. For
each study, we report the number of patients, mean age, mean preoperative BMI, mean OR time, type of
GJ (sutured or stapled), length of hospital stay, overall complication rate, leak rate, GJ stricture rate
and mortality. There were a total of 3337 patients in these 9 studies with 1381 in a robotic arm and 1956
in the laparoscopic arm. The mean age in RRYGB and LRYGB group was 43.3 years and 42.4 years,
respectively. Average BMI was 45.8 in RRYGB patients and 46.7 in LRYGB patients.

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The mean OR time was 211.9 min in robotic arm versus 185.1 min in the laparoscopic arm. Three studies
report a significantly shorter operative time in a robotic group13, 15, 19while four studies report a significantly
longer operative time in a robotic arm.16, 17, 20, 21 This may be compounded by the fact that in all the studies,
a sutured GJ was done in the robotic arm, while a stapled GJ was done in the laparoscopic arm in six out of
nine studies. The average length of stay was 5 days in robotic group versus 7.1 days in the laparoscopic
group. Three studies found a statistically significant shorter hospital stay in the robotic arm 15, 20, 21while one
study found a significantly longer stay in the robotic arm. 19The overall complication rate was 12.2% in
RRYGB group versus 13.3% in LRYGB group. Buchset al.21found a significantly lower incidence of
complication in a robotic group (11.6% vs. 16.1%). The average leak rate across studies was 0.9% in RRYGB
versus 1.6% in LRYGB, while the GJ stricture rate was 3.1% in a robotic arm and 3.2% in the laparoscopic
arm. Snyder et al14and Buchset al. 21 found a significantly lower leak rates in RRYGB. Benizriet al. 19found a
significantly higher GJ stricture rate for a robotic arm. The overall mortality in both groups was 0.05%. Of all
the published studies, there is only one prospectively randomized trial by Sanchez et al. 13The other studies
are either comparative studies, case series, retrospective or prospective analyses. There is a surgeon skill
bias at play in the majority of these studies as it is very difficult to find a surgeon equally skilled in both
robotic and laparoscopic techniques. Most of the surgeons and their teams become proficient in either of the
two techniques. But large comparative studies and systematic reviews do offer some tendencies for robotic
bariatric surgery. 22-25
The learning curve of both LRYGB and RRYGB has been studied. Learning curve for LRYGB has been
reported to be 75-100 cases in order to normalize complications. 26-27Buchset al. 12 analysed the
learning curve for RRYGB and found it to be 14 cases in order to achieve mastery for a surgeon well
versed in laparoscopic surgery but not in bariatric procedures. Yu et al. 28studied complications in first
100 cases of RRYGB, and found no leaks and one reoperation. The published literature seems to
suggest that the learning curve for robot assisted RYGB is shorter than laparoscopic technique.

Robotic Sleeve Gastrectomy

Sleeve gastrectomy is increasingly becoming popular and has become the most common bariatric
procedure performed all over world because of its low morbidity, excellent outcome and perceived
technical simplicity. It is especially so in Indian sub-continent because of high prevalence of a
vegetarian population, who tend to choose a restrictive procedure rather than a malabsorptive one.
Sleeve gastrectomy has a long staple line with the potential to leak, and a precise and safe dissection
is required in the area of the left crus and hiatus entirely to mobilize the fundus. Compared to
laparoscopic surgery, robotic surgery offers the possibility for endowrist, and this action facilitates the
hiatal dissection and over sewing of the staple line. The first robotic sleeve gastrectomy, as part of the
BPD/DS, was performed in 2000 29, but the first series of standalone robotic sleeve gastrectomies was
reported in 2011.30We are performing robotic sleeve gastrectomies since 2012 and having a series of
more than 150 robotic sleeve gastrectomies.

Our (Imas) Technique

Instrumentation
The following robotic instruments are used for a RSG in a da Vinci Si system (Intuitive Surgical,
Sunnyvale, CA).
Large needle driver
Ultrasonic shears
Atraumatic bowel grasper forceps
Laparoscopic / Robotic staplers
Patient positioning & OR Setup (Fig.17)
The patient is positioned supine with arms by the side.After cleaning and draping orogastric tube
placed. Footboard is properly secured and straps placed at level of upper thigh. The body
warming blanket is placed.

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Port position and docking
Pneumoperitoneum is achieved using closed technique to 15 mm Hg using a veress needle at
palmer’s point. All the distances are measured after insufflation of abdomen as they significantly
change after Pneumoperitoneum is created, especially in morbidly obese because of pendulous
abdominal wall. The minimum inter-trocar distance recommended in robotic surgery is 8-10 cm.
But the actual distance intraperitoneally in morbidly obese individuals is significantly shorter than
the distance measured on the skin. This factor has to be taken into account and trocars should be
placed at maximum possible distance to avoid external arm clashing of robot. Pre-emptive
analgesia (0.5 % bupivacaine) infiltration is done before incision at all port sites.Camera port (12
mm diameter, 150 mm long trocar) is placed 20 cm below the xiphisternum slightly to left of
midline under vision using a zero degree 10 mm scope to avoid any inadvertent visceral injury.
Following this, one assistant and three da Vinci trocars are placed as follows (Fig. 18).

R1: (8 mm da Vinci® cannula) is placed in left mid clavicular line approx. 20 cm from xiphisternum
R2 (8 mm da Vinci® cannula) is placed in right hypochondrium in mid clavicular line taking care
that the entry of port is below the margin of liver.
R3 (8 mm da Vinci® cannula) is placed in left flank at the level of camera port.
Assistant port (12 mm diameter) is placed in between camera port and R2 with a distance of at
least 10 cm from both of them.
A 5 mm epigastric port is made and used for placing Nathanson liver retractor for retracting left
lobe of liver.
The port placement needs to be adjusted based on the body habitus of the patient so as to
prevent external arm collision and provide optimal exposure. A diagnostic laparoscopy is done to
look for any adhesions / hernias / inadvertent injury during abdominal wall access.
The da Vinci®patient brought from left shoulder of the patient (parallel docking).
Parallel docking gives more room to the anesthetist, as well as endoscopist for intra-operative
gastroscopy. The third arm of the robot comes from left side of the patient. The assistant surgeon
stands by the side for complimentary maneuvers (i.e., suction, stapling, retraction etc.).

Operative Technique:
The patient is placed in steep reverse trendelenberg position. All three arms of da Vinci surgical system ®are
used. A 38 Fr Gastric Calibration Tube (GCT) is used after induction to empty out the gastric contents and
kept in place to guide the sleeve formation. We place a nasogastric tube inside the GCT to be able to
efficiently suck out the gastric secretions, which otherwise tend to pool in the wide end of GCT. Care is taken
to empty out all the gastric secretions, especially from the fundus, so as to facilitate hiatal dissection. The
GCT is then withdrawn into esophagus before starting the gastrolysis. Pylorus is identified and using a 5 cm
umbilical tape distance from pylorus is measured and gastrolysis is performed along the greater curvature of
stomach using harmonic scalpel (Fig. 19). Stomach is elevated using bowel grasper in R2, while bowel
grasper in R3 is used to retract gastrocolic ligament laterally while harmonic scalpel in R1 is used for
gastrolysis (Fig. 20).Dissection is done remaining juxtastomachto avoid injury to gastroepiploic vessels. The
short gastric vessels from gastrosplenic ligament are divided. One can appreciate a bilaminar avascular
parchment like membrane. Left crus is completely defined mobilizing fundus adequately. Care is taken that
the bougie is withdrawn in the esophagus during this step; else it can lead to difficulty in dissection around
the hiatus. Hiatus hernia if identified, should be repaired to avoid gastroesophageal reflux. Distal portion of
gastrocolic ligament is divided until 4-5 cm from pylorus. Posterior adhesions of the stomach to the
pancreas are taken down to fully mobilize the stomach.GCT is pushed forward by the anaesthetist and
guided by the surgeon into first part of duodenum using bowel graspers. Rotation of bougie by anaesthetist
and right traction by surgeon helps negotiate the pylorus. This leads to bougie nicely resting along the
lesser curve of the stomach and helps in formation of an even sleeve. Sleeve of stomach is created using
articulating stapler from assistant port while the console surgeon applies traction on the stomach so that it
lies in the right orientation.

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It is important to avoid any spiraling or uneven staple line. Sequential stapling with first green
load and subsequent blue loads is performed while not being very snug to the bougie (Fig. 21).

Stapling at incisuraangularisdone carefully to prevent narrowing. Transection is continued towards the angle
of his along the lateral edge while maintaining lateral symmetrical traction. A straight staple line is formed
without any spiral either anteriorly or posteriorly to prevent a functional obstruction. Finally, transection is
done at angle of HIS (Fig. 22), avoiding an acute angle at GE junction.Imbrication of staple line is done
keeping bougie in place using barbed 2-0 running suture as shown in figure below.(Fig 23)

We always do a check gastroscopy with saline immersion all the cases so as to rule out any leak,
bleeding or obstruction.

Literature review
31-35
Five studies have been published, which focus on robotic sleeve gastrectomy (RSG). Diamantiset.
31
al. published a feasibility study that included 19 patients who underwent RSG. Their mean OR time was
32
95.5 min and reported complication rate was zero. Aylooet al. compared 30 robotic with 39 laparoscopic SG
procedures and found no difference in length of hospital stay, complication rates or excess body weight loss
at 1-year. They found a significantly longer OR time for RSG (135 vs. 114 min), due to the fact that they had
oversewn the staple line in the robotic arm and not in the laparoscopic arm.
Vilallongaet al.33reported that the learning curve of performing RSG is over by 20 cases. He also
published a large comparative series on SG including 100 patients each in robotic and laparoscopic
arms. 34They found that OR time was significantly longer in a robotic group by 12 min. There was no
significant difference in other peri-operative parameters or complication rate. They did found that leaks
occurred only in those patients in whom they did not over-sew the staple line, but used a buttress
material. They concluded that RSG is a good stepping stone to robotic gastric bypass and RBP.
Romero et al. 35 published their experience of 134 RSG cases and compared it with descriptive results
of a systematic review of laparoscopic SG (n = 3148). The OR time was significantly higher by 12 min (P
= 0.006), whereas the length of stay was lower by 1.1 days in a robotic group (P ≤ 0.005). Leaks were
found in 0 RSG versus 1.97% laparoscopic SG (P = 0.101); strictures in 0 versus 0.43% (P = 0.447);
bleeding in 0.7 versus 1.21% (P = 0.594); and mortality in 0 versus 0.1% (P = 0.714), respectively.
We performed a comparative study of RSG in morbidly obese (MO) versus SO patients at our
center (iMAS). 34 SO patients were compared with 78 MO patients who underwent robotic SG with
over sewing of the staple line in all the cases. The mean OR time was 116.3 min and mean docking
time was 8.9 min. There was no significant difference in OR time, length of hospital stay or
complications in between the two groups. Thus, presumably, using a robotic system overcomes
many difficulties in the SO patients and enables the surgeon to perform the similar procedure as
in MO patients with equal precision, similar time and little or no extra effort.

Robotic Biliopancreatic Diversion with Duodenal Switch

The biliopancreatic diversion with duodenal switch is technically the most advanced bariatric
procedure requiring skillful dissection and intracorporeal suturing. It consists of a sleeve
gastrectomy and a distal bypass. The first robotic BPD/DS was performed in October, 2000 soon
after the introduction of the da Vinci TM system.29

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Our (Imas) technique-
5.1.1. Patient position and OR set up (Fig 24).
Patient in supine position with 200reverse trendelenberg tilt. Patient cart brought in from head end
of patient.

Port position (Fig 25)

Three robotic arms with one assistant trocar and Nathanson’s liver retractor placed.

Diagnostic laparoscopy and bowel marking

Illeo-caecaljunction(ICJ) identified and small bowel marked at 100cm (common limb) and 250 cm
from ICJ (Roux limb 150cm) (fig 26).
Marked bowel at 250 cm is hitched to anterior abdominal wall.Retroduodenal tunnel made and
duodenum transected at D1 (fig 27).
Hand sewn anastomosis made using 3-0 barbed absorbable suture between duodenum and ileum
(duodeno-illeostomy) at 250 cm mark using 3-0 absorbable barbed suture (Fig 28).
Jejuno-illeostomy made at 100 cm mark thus making a common limb of 100 cm using 60 mm
blue/tan cartridge(Fig 29). Enterotomy closed using absorbable suture in two layers.

Loop of bowel divided just proximal to duodeno-illeostomy (Fig 30).

Intraoperative endoscopy /Methylene blue dye leak test done for patency of anastomosis.Mesenteric
defects closed using non absorbable sutures.Sudan et al. reported the outcomes, learning curve and
technique of robotic biliopancreatic diversion with duodenal switch (RBPDDS). 36-38 They published
experience of 47 patients who underwent this procedure with a mean BMI of 45 kg/m2and the mean age
of 38 years. The median OR time was 514 min, which decreased to 379 min in last 10 patients. There
were four leaks, three conversions and no mortality in the series. The learning for RBPDDS was found
to be around 50 cases after which the complications and OR time normalized.37

Robotic Adjustable Gastric Banding

4
Adjustable gastric banding was the first bariatric procedure performed using a robot. Technically it is
considered the simplest of all bariatric procedures. Number of procedures (AGB) has decreased
tremendously all over the world because of low efficacy and high revision/complication rate associated with
it. There have been few studies published in the literature looking at outcomes of robotic assistance
39- 41 42
in AGB, and showed little benefit for using the robot. Edelsonet al. reported the largest
study with 287 patients of robotic AGB compared with 120 patients who underwent laparoscopic
AGB. No significant differences were found in the operating room (OR) times, hospital stay,
complication rates, or excess weight loss. They did find a shorter operative time by 12 min in the
robotic arm when compared for SO patients. As of now, robot is used mostly for managing
complications and revising gastric band to another weight loss procedure.

328
Robotic Revisional Bariatric Procedures
Revisional bariatric procedures are increasing owing to problems of weight regain or as a complication
of any other bariatric procedure. These are difficult and complex situations in which use of robotics
hold a great potential. The anatomy in these situations is distorted which along with adhesions present
a challenge to the surgeons. Complication rates of laparoscopy in these situations have been high with
leak rates of 13.2% and mortality of 2%.43 There is a couple of studies available on RBP that show
better outcomes with robot assistance in these challenging cases.44-45Snyder et al.44reviewed 99
cases that were revised using robot assistance at one Centre. The mean BMI decreased from 44.8 to 29
kg/m2after 3 years. The overall complication rate was 17% with a 90 days readmission rate of 24%.
However, there was no leak, hemorrhage or mortality in the series, which is promising considering the
high incidence of these complications in these situations. Buchset al.45 compared the outcomes of
RBP performed by robotic (n = 11), laparoscopic (n = 21) and open (n = 28) method. They found that the
robotic arm had fewer complications (0 vs. 14.3% for laparoscopy, vs. 10.7% for open), but took longer
to perform (352 vs. 270 vs. 250 min, respectively). There were fewer conversions in robotic group (0 vs.
14.3% for laparoscopy) and a significantly shorter hospital stay (6 vs. 8 vs. 9 days, respectively). We
have performed more than 15 robotic revisional procedures which include robotic re-sleeve, robotic
conversion of sleeve to gastric bypass, robotic conversion of sleeve to duodenal switch and robotic
revision of vertical gastric banding.
DISCUSSION
This review of published literature reveals that the routine use of robotics in bariatric surgery is a safe
and feasible option. Several studies have shown a lower complication rate with the robotic platform
including leaks, hemorrhage and stricture. The advantage of robotics is perceived much more in
challenging situations like RBP. However, in order to graduate to these advanced procedures, one has
to move a step by step, starting with RSG and moving on to RRYGB and RBP.
Robotic surgery is a team effort, and more so in bariatric surgery, where the role of an
experienced bedside surgeon cannot be understated, as he is responsible for stapling (if robotic
staplers are not used). As the main surgeon is separated from the patient, while performing
robotic surgery, the assistant surgeon has to be trained enough to help him perform difficult tasks
and also to take care of any emergency situation arising during the procedure. The role of a
trained scrub nurse and OR technician is also very important in streamlining the conduct of the
procedure and prevents any wastage of time and resources.
The learning curve of RRYGB has also been shown to be shorter as compared to LRYGB. 12The entire
team learns with the surgeon and develops experience about patient safety
precautions, OR set-up, and
type of instruments needed, thus
leading to better OR times with better patient outcomes.

Another advantage, which comes with the use of the robotic system, is improved ergonomics and
lesser operator fatigue. Ergonomics in laparoscopic surgery can be very challenging with big
patients and uncomfortable postures, which lead to surgeon fatigue and work related
musculoskeletal symptoms.46Robotics provides the advantage of more degrees of freedom,
which is advantageous in performing difficult dissection and sutured anastomosis.
There has been a concern about cost every time use of the robotic system is considered as the
direct costs are generally higher for the robotic approach in bariatric procedures like RYGB. 47
However; Hagen et al.18took into consideration the total costs including the complications and
readmissions. They found that the cost of RRYGB was lower as compared to LRYGB when all the
factors were counted for. There is also a saving due to decrease in number of laparoscopic
staplers used in robotic procedures, by doing a hand-sewn anastomosis.
At the end of the day, the big question to be answered is whether the use of robotics is going to stay or
will it perish with time like many fancy technologies. Looking at the basic concept of computer-
assisted navigational surgery, robotics provides an enabling platform in between surgeon and the
patient. It provides augmented and higher quality inputs from the patient to the surgeon, and his output
is refined to a superior quality before reaching back to the target. According to us, this should not be
analyzed in terms of features of the present machine that is available for use, but in terms of the
potential in the concept of using a digital interface to interact with patients and enhance the
performance of the surgeon. With the advent of newer technologies in robotics like fluorescence,
integration of images, virtual and augmented reality, tele-surgery, single site platforms, natural orifice
surgery and haptic feedback, we believe that it will provide an empowering tool to the surgeons, which
can potentially change the way surgery is practiced today.
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134 cases and comparison with a systematic review of the laparoscopic approach. ObesSurg 2013;23:1743-52.
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SurgEndosc 2007;21:729-33.
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laparoscopic biliopancreatic diversion with duodenal switch. Ann Surg 2012;255:940-5.
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MANAGEMENT OF BPH
-Dr. Lovekesh Kumar

BPH is defined as microscopic BPH, macroscopic BPH, or clinical BPH. Proliferative process originates
in the transition zone and the periurethral glands. Androgens play a passive role in the proliferative
process. Growth factors such as epidermal growth factor (EGF) are involved through autocrine and
paracrine stromal-epithelial interactions. Digital rectal examination (DRE) provides a relatively crude
estimate of prostate size when compared with measurements using transrectal ultrasonography. In the
absence of adenocarcinoma, the PSA value may be used as a surrogate for prostate volume.

DIAGNOSIS
The complex of symptoms now commonly referred to as “LUTS” is not specific for BPH. The
American Urological Association (AUA) BPH guidelines were presented in 1994 and 2003, were
updated in 2010. Initial Evaluation:
Medical History
Detailed medical history should be obtained to identify other causes of voiding dysfunction or
cormorbidities that may complicate treatment. Specific additional areas to discuss when taking
the history of a man with BPH symptoms include a history of hematuria, UTI, diabetes, nervous
system disease (e.g., Parkinson disease or stroke), urethral stricture disease, urinary retention,
and aggravation of symptoms by cold or sinus medication. Use of a voiding diary (recording
times and volume) may help identify patients with polyuria or other nonprostatic disorders.
Physical Examination
A DRE and a focused neurologic examination should usually be performed. In addition,
examination of the external genitalia is indicated to exclude meatal stenosis or a palpable urethral
mass and an abdominal examination is necessary to exclude an overdistended, palpable bladder.
The size of the prostate is not critical in deciding whether active treatment is required.
Urinalysis
More importantly, urinalysis assists in distinguishing UTIs and bladder cancer from BPH. Urine
cytology should always be requested in men with severe irritable symptoms and dysuria,
especially if they have a smoking history.
Serum Creatinine Measurement
The AUA guidelines on BPH and the Sixth International Consensus report no longer recommend routine
creatinine measurement in the standard patient. Elevated serum creatinine levels in a patient with BPH is an
indication for imaging studies (usually ultrasonography) to evaluate the upper urinary tract.
Serum Prostate-Specific Antigen
Measurement of the serum PSA value should be performed in patients in whom the identification
of cancer would clearly alter BPH management.
Symptom Assessment
There are multiple symptom scores as AUA-7 Symptom Index, IPSS, Madsen and Iversen, Boyarsky and the
International Continence Society Study on BPH. However, the AUASI was validated as to its clarity.

331
Patients with mild symptoms (with a score of 0 to 7) were assigned to watchful waiting; those with
moderate (8 to 19) or severe (20 to 35) symptoms would undergo further testing or treatment, or
both. IPSS is now the U.S. and international standard. However, the IPSS cannot be used to
establish the diagnosis of BPH. , the IPSS is the ideal instrument to grade baseline symptom
severity, assess the response to therapy, and detect symptom progression in those men managed
by watchful waiting. Degree of bothersomeness should be taken into account(how a given level of
symptoms affects each man’s quality of life).

American Urological Association (AUA) Symptom Index for Benign Prostatic Hyperplasia

NOT LESS LESS THAN ABOUT HALF MORE THAN ALMOST

AT THAN 1 HALF THE THE TIME HALF THE ALWAYS
ALL TIME IN TIME TIME
5
1. Over the past month, how often
have you had a sensationof not
0 1 2 3 4 5
emptying your bladder completely
after you finishedurinating?
Over the past month, how often
have you had to urinate again
less than 2 hours afteryou finished 0 1 2 3 4 5
urinating?
Over the past month, how
often have you found you
stopped and started again
0 1 2 3 4 5
several times when you
urinated?
Over the past month, how
oftenhave you found it difficult to
0 1 2 3 4 5
postpone urination?
Over the past month, how often
have you had a weak 0 1 2 3 4 5
urinary stream?
Over the past month, how often
have you had to push orstrain to 0 1 2 3 4 5
begin urination?

7.
Over the past month, how
many times did you most
typically get up to urinate
from the time you went to
5 ormore
bedatnight until the time None 1 time 2 times 3 times 4 times
times
you got up in the morning?

AUA Symptom Score = sum of

questions A1
to A7

Benign Prostatic Hyperplasia (BPH) Impact Index

1. Over the past month, now much physical discomfort did Only a
None Some A lot
any urinary problems cause you? little
2. Over the past month, how much did you worry
None Only a little Some A lot
about your health because of urinary problems?
3. Overall, how bothersome has any trouble with urination Notat all Bothers me a Bothersmes Bothers mea
been during the past month? bothersome little ome lot
Over the past month, how much of the timehas any
urinary problem kept you from doingthekinds of things Most of
None of A little of the
you would usually do? the All of thetime
the time time
time
BPH Impact Index = sum of questions B1 to B4
Additional Diagnostic Tests
Additional testing should be considered after the initial evaluation if there is a significant chance
the patient’s LUTS may not be due to BPH.

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DIAGNOSTIC TESTS IN MEN WHO REQUIRE SURGERY FOR BPH
Surgery is generally recommended if the patient has refractory urinary retention (failing at least
one attempt of catheter removal) or any of the following conditions clearly secondary to BPH:
recurrent UTI, recurrent gross hematuria (resistant to 5α-reductase inhibitor therapy), bladder
stones, renal insufficiency, or large bladder diverticula.
If there is reason to suspect that the patient’s urinary retention may be due to detrusor
hypocontractility, then urodynamic studies (e.g., filling cystometry) may be helpful. Cystoscopy is
appropriate to consider before the operative procedure to help plan the most prudent approach.
The presence of infection and hematuria in patients should prompt appropriate evaluation and
therapy for these conditions before treatment of BPH.

Uroflowmetry
The results of uroflowmetry are nonspecific for causes of the symptoms. For example, an
abnormally low flow rate may be caused by an obstruction (e.g., hyperplastic prostate, urethral
stricture, meatal stenosis) or by detrusor hypocontractility.
Flow rate measurements are inaccurate if the voided volume is less than 125 to 150 mL.
The peak flow rate (PFR; Qmax) more specifically identifies patients with BPH than does the
average flow rate (Qave).
Although PFR decreases with advancing age and decreasing voided volume, no age or volume
correction is currently recommended for clinical practice.
Although considerable uncertainty exists, patients with a PFR greater than 15 mL/sec appear to
have somewhat poorer treatment outcomes after prostatectomy than patients with a PFR of less
than 15 mL/ sec.
A PFR of less than 15 mL/sec does not differentiate between obstruction and bladder decompensation.

Postvoid Residual Urine Volume

PVR urine volume does not correlate well with other signs or symptoms of clinical BPH. Large
PVR urine volumes may predict a slightly higher failure rate with a strategy of watchful waiting.
However, the threshold volume defining a poorer outcome is uncertain.
PVR urine volume is best viewed as a “safety parameter.” Men with significant PVR amounts
should certainly be monitored more closely if they elect nonsurgical therapy, particularly if
antimuscarinic therapy is chosen.
Pressure-Flow Studies
If the initial evaluation, flow rate, and PVR urine volume are not sufficiently suggestive of BOO,
further urodynamic assessment by pressure-flow studies should be considered, especially if an
invasive treatment is considered (i.e., surgery) or if surgical treatment has failed. Pressure-flow
studies differentiate between patients with a low PFR secondary to obstruction and those whose
low PFR is caused by impaired detrusor contractility.

Urethrocystoscopy
Urethrocystoscopy is not recommended to determine the need for treatment. The test is recommended
for men with LUTS who have a history of microscopic or gross hematuria, urethral stricture disease (or
risk factors such as history of urethritis or urethral injury), bladder cancer or suspicion of carcinoma
in-situ, or prior lower urinary tract surgery (especially prior TURP). Urethrocystoscopy may be
considered in men with moderate to severe symptoms who have chosen (or require) surgical or other
invasive therapy to help the surgeon determine the most appropriate technical approach.

Imaging of the Upper Urinary Tract

Upper urinary tract imaging is not recommended in the routine evaluation of men with LUTS
unless they also have one or more of the following: hematuria, UTI, renal insufficiency
(ultrasonography recommended), history of urolithiasis, or history of urinary tract surgery.

ASSESSING THE EFFECTIVENESS AND SAFETY OF MEDICAL THERAPY

The goals of treatment for BPH include relieving LUTS, decreasing BOO, improving bladder emptying,
ameliorating detrusor instability(The definition of bladder overactivity (detrusor instability) is the
development of a detrusor contraction exceeding 15 cm H2O at a bladder volume less than 300 ml),
reversing renal insufficiency, and preventing disease progression, which may include a deterioration of
symptoms, future episodes of gross hematuria, UTI, AUR, or the need for surgical intervention.

333
Watchful Waiting or “Self-Help”
A significant proportion of men with LUTS will not choose medical or surgical intervention because the
symptoms are not bothersome, the complications of treatment are perceived to be greater than the
inconvenience of the symptoms, and there is a reluctance to take a daily pill owing to side effects and/or the
cost of treatment. Watchful waiting is often the patient-driven treatment of choice in the absence of absolute
indications for intervention. The severity and bother due to symptoms may be improved by simple measures
such as decreasing total fluid intake especially before bedtime, moderating the intake of alcohol- and
caffeine-containing products, and maintaining timed voiding schedules.

MEDICAL THERAPY
Medical therapies extensively investigated for BPH include α-adrenergic blockers, 5α-reductase
inhibitors, aromatase inhibitors, and numerous plant extracts. Newer therapies include antimuscarinic
drugs and phosphodiesterase inhibitors (PDEIs) and several combinations of these agents.
Medical therapy is currently considered the preferred treatment alternative for those individuals
who lack absolute indications for surgery.

α-Adrenergic Blockers
CLASS OF α-ADRENERGIC BLOCKER DOSE
Nonselective 10 mg bid
Phenoxybenzamine
α1

Prazosin 2 mg bid
IR Alfuzosin 2.5 mg tid
Indoramin 20 mg bid
Long-Acting α1
5 or 10mg qid
Terazosin
Doxazosin 4 or 8 mg qid
Alfuzosin SR 10 mg
Subtype Selective
0.4 mg qid
Tamsulosin
Silodosin 8 mg qid

Two subtypes of the α receptor (α1 and α2). Efficacy and toxicity are mediated primarily by the α1
and α2 receptors, respectively. 98% of the α1 receptors are localized to the prostatic stroma .The
adverse events associated with α-adrenergic blockers are dizziness,asthenia, orthostatic
hypertension & retrograde ejuculation.
Terazosin. In men with medically controlled hypertension, terazosin had no clinically significant
effect on blood pressure, whereas in men with poorly controlled medically treated hypertension,
terazosin significantly lowered blood pressure.
Doxazosin. The half-life of doxazosin is longer than that of terazosin (22 vs. 12 hours).Iinterim analysis
of the Treatment to Prevent Heart Attack Trial (ALLHAT) questioned the use Anti-Hypertensive and
Lipid Lowering of doxazosin in men at risk for developing congestive heart failure.
Tamsulosin is currently the most widely employed α1 antagonist investigated for BPH. One of the
features of tamsulosin is that it exhibits some degree of specificity for the α 1A-adrenergic
receptor .There is no need of dose titration.
Intraoperative floppy iris syndrome (IFIS) complicates approximately 2% of cataract surgery
cases. The clinical manifestations of IFIS are poor preoperative pupil dilation, iris billowing and
prolapse, and progressive intraoperative miosis. It appears that α 1A is the predominant receptor
subtype in the iris dilator muscle as well. The persistence of IFIS long after the discontinuation of
tamsulosin suggests a semipermanent muscular atrophy and loss of tone. IFIS does not occur
until patients have been on tamsulosin therapy for 4 to 6 months. IFIS can also occur up to
several years after discontinuation of tamsulosin. Prevention of IFIS by withdrawing tamsulosin
preoperatively has not shown consistent benefit. Therefore, in a patient with a known diagnosis
of cataract, prescribing physicians may wish to consider involving the patient’s cataract surgeon
before initiating tamsulosin or α-adrenergic blocker treatment.
Alfuzosin. The primary limitation of alfuzosin was a requirement for multiple daily doses (2.5 mg three
times a day or 5 mg twice a day). Extended-release or slow-release (SR) alfuzosin is a new formulation
that allows for a once-daily dosing regimen without dose titration. Because of the lack of adverse
effects and blood pressure changes, alfuzosin has been described as a uroselective drug.

334
Silodosin This agent shows 162:1 selectivity for α1A versus α1B adrenoceptors and is achieving
promising results. A selective α1-adrenergic receptor antagonist, received U.S. Food and Drug
Administration (FDA) approval in October 2008. 8 mg once-daily silodosin taken for 12 weeks cause
significant and rapid improvement of the IPSS. Minimal effects on the cardiovascular system, without
any meaningful prolongation of the QT interval. The most common drug-related side effect was
retrograde ejaculation (better described as anejaculation). Silodosin has the highest selectivity for the
vas deferens (7.5-fold), followed by naftopidil (4.3-fold), alfuzosin (3.8fold), tamsulosin (2.6-fold), and
prazosin (2.5-fold). These results suggest that high tissue selectivity for the vas deferens over the
urethra may contribute to the incidence of abnormal ejaculation.
Naftopidil. A relative selective α1D-adrenergic receptor antagonist. Whereas naftopidil
monotherapy decreased the IPSS for storage symptoms, tamsulosin monotherapy decreased the
IPSS for voiding symptoms .

Androgen Manipulation
The rationale for androgen suppression is based on the observation that the embryonic development of the
prostate is dependent on the androgen dihydrotestosterone (DHT). Androgen suppression causes
regression primarily of the epithelial elements of the prostate. Reducing prostate volume is thought to
decrease the static component of BOO resulting from BPH. . Maximal reduction of prostate volume after
initiation of androgen suppression is achieved within 6 months. , it is reasonable to assume that subjects
with larger prostates achieve the greatest therapeutic benefit. Finasteride and dutasteride are the only drugs
available that achieve androgen suppression with acceptable tolerability.
Finasteride and dutasteride alter the natural history of urinary retention in men with LUTS and
enlarged prostates. In the recently reported REDUCE study, dutasteride reduced the incidence of
prostate cancer by 23%. Antiandrogens have also been investigated for BPH. These studies failed
to demonstrate statistically significant treatment-related efficacy. The equivocal efficacy and
problematic toxicity of antiandrogens limited the enthusiasm for marketing these drugs for the
treatment of BPH. The role of gonadotropinreleasing hormone antagonists requires further study.

Finasteride. Competitive inhibitor of the enzyme 5α-reductase type 2 isozyme. Finasteride does not
reduce DHT levels to castrate levels because circulating testosterone is converted to DHT by type 1
isozymes that exits in skin & liver . Decreased libido, ejaculatory disorder, and impotence are side
effects. The Proscar Long-Term Efficacy and Safety Study (PLESS) was done for finastride. The unique
findings of the PLESS were related to decrease incidences of both AUR and surgical intervention for
BPH Finasteride reduces group mean serum PSA levels approximately 50%. Finasteride prevents
recurrent gross hematuria secondary to BPH & effective in post prostatectomy hematuria.
Dutasteride. Dutasteride is a dual inhibitor of 5αreductase types 1 and 2 and therefore has a
greater impact on suppressing serum DHT levels
Zanoterone. Zanoterone is a steroidal competitive androgen receptor antagonist. The incidence
and severity of adverse clinical events(breast pain & gynecomastia) and the equivocal efficacy
precluded further development of this drug for BPH.
Flutamide. Flutamide is an orally administered nonsteroidal antiandrogen that inhibits the binding
of androgen to its receptor.
Cetrorelix. Cetrorelix is a gonadotropin-releasing hormone antagonist that has been investigated for
BPH. A potential advantage of a gonadotropin-releasing hormone antagonist over the luteinizing
hormone–releasing hormone agonists in the treatment of BPH is the ability to titrate the level of
androgen suppression. The primary disadvantage of cetrorelix and other gonadotropin-releasing
hormone antagonists will be the requirement for an injection and the cost.

Aromatase Inhibitors.
Atamestane is a highly selective aromatase inhibitor that lowers both serum and intraprostatic
levels of estradiol and estrone. The development of atamestane for BPH was suspended because
of negative clinical findings
Combination Therapy with α-Adrenergic Blockers and 5α-Reductase Inhibitors
The results of the MTOPS( Medical Therapy of Prostatic Symptoms) trial suggest that the combination
of doxazosin and finasteride exerts a clinically relevant, positive effect on rates of disease progression.
Men who received combination therapy were significantly less likely to experience BPH progression
than those receiving either monotherapy or placebo, with risk reduction rates of 39% for doxazosin,
34% for finasteride, and 67% for combination therapy compared with placebo.Combination therapy
becomes an economically stronger option in patients at higher risk for progression.

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Combination versus Avodart or Tamsulosin (CombAT) Trial
Combination of dutasteride and tamsulosin was more effective than either drug alone.

Anticholinergic (Antimuscarinic) Receptor Blockers

OAB symptoms may coexist with BPH or BOO and may be either secondary to that obstruction or
unrelated. Traditionally, in the treatment of OAB symptoms the use of antimuscarinic (commonly
called anticholinergic) agents is often employed in women. However, in men there is always anxiety
that these antimuscarinic agents decrease detrusor contractility and could, in theory, increase the risk
of urinary retention, particularly in a man with significant obstruction. If not leading to AUR, then the
risk of increasing PVR might lead to other complications, such as infection.
Combination therapy consisting of α1-adrenoceptor antagonists with antimuscarinic agents
represents an effective and relatively safe treatment modality in select patients with OAB
coexisting with BPH, with minimal risk of retention or AUR in carefully selected men. Therapy
may improve both storage and voiding symptoms.
Men with significant obstruction and large, persistent residual urine volumes(>200ml) should be
considered for surgical therapy rather than the addition of antimuscarinic agents

Phosphodiesterase Inhibitors (sildenafil, tadalafil, and vardenafil ,udenafil)

There is an as yet undetermined link between LUTS/BPH and ED.There is now good level 1 evidence of
a beneficial effect of PDEIs on urinary symptoms. PDEIs improve urinary symptoms scores. It is likely
that PDEI treatment will be of value, especially for men with LUTS and significant ED.However, in the
studies so far available to us there are no significant changes in PFR, suggesting that the effects of
PDEIs may be either more focused on bladder muscle function than on prostatic tissue or are more
profound on storage symptoms than on bladder outflow obstruction itself.
The candidate mechanisms include the following: an ultimate effect leading to smooth muscle
relaxation in prostatic, bladder or erectile tissues appears to be crucial ,.
Pelvic atherosclerosis
Autonomic hyperactivity
The calcium-independent Rho-kinase activation pathway
Reduced nitric oxide (NO) levels, which is probably the best explored process so far
The pelvic atherosclerosis theory suggests that just as penile ischemia leads to smooth muscle
loss in the penis so smooth muscle damage in the bladder would decrease compliance and
predispose to replacement of bladder smooth muscle with collagen and fibrosis.
Conditions promoting pelvic atherosclerosis such as hypertension, smoking, hypocholesterolemia,
and diabetes mellitus(metabolic syndrome) are implicated in both ED and LUTS.
the concomitant use of α-adrenergic blockers and PDEIs may lead to symptomatic hypotension in
some patients because both are vasodilators.The coadministration of doxazosin (4 and 8 mg
daily) and tadalafil (5 mg/day or 20 mg as a single dose intermittently) leads to further lowering of
blood pressure, and this combination is not recommended by the manufacturers.
Phytotherapy
Phytotherapeutic agents for LUTS/BPH have gained widespread use since about 1990. Serenoa
Repens (Saw Palmetto Berry). The extract of the berry of the American saw palmetto, or dwarf
palm plant, is the most popular phytotherapeutic agent available for the treatment of BPH.
Phytotherapeutic products are not the actual plant but are extracts derived from either the
roots, the seeds, the bark, or the fruits of the various plants used.The composition of plant
extracts is very complex. They contain a wide variety of chemical compounds, which include
phytosterols, plant oils, fatty acids, and phytoestrogens.The three mechanisms of action that
have received the greatest attention are anti-inflammatory effects, 5α-reductase inhibition,
and growth factor alteration. The anti-inflammatory effects are modulated by effects on
prostaglandin synthesis.Data concerning the efficacy are not conclusive.

Acute Urinary Retention

AUR may be “spontaneous” where it is usually associated with previous LUTS suggestive of BPH.
Alternatively, it may be “precipitated” by some other factor, such as the effects of various medications,
particularly anticholinergic or sympathicomimetic agents, which are commonly found in cough and
cold remedies. Urinary infection, excessive fluid intake, and the consequences of surgery
(postoperative pain or the effects of anesthesia or analgesia or loss of mobility) may precipitate AUR.

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Analysis of the placebo arms of a series of large studies such as the PLESS evaluation of
finasteride, MTOPS, and the CombAT study indicate that increasing age, the presence of LUTS, a
low PFR, and prostatic enlargement and/or raised PSA increase the risk of AUR.
If urinary retention is caused by increased sympathetic activity at the level of the prostatic
smooth muscle, an α-adrenergic blocker should increase the likelihood of spontaneous voiding
after catheter removal.In the MTOPS trial, finasteride or combination therapy of finasteride with
doxazosin, but not doxazosin alone, reduced the incidence of AUR

Minimally Invasive and Endoscopic Management

Medical management has reduced greatly the indications and the number of patients of TURP.

INTRAPROSTATIC STENTS
One of the earliest attempts to find less traumatic methods of treating symptomatic BPH was the
introduction of either temporary or permanent intraprostatic stents .The idea of using stents for
splinting the lobes of the prostate was derived from their original use in the cardiovascular system.
Eventually it became clear that their major role was likely to be found in the management of
patients who were unfit for surgery, in either the short or the long term, in which the alternative
would have been months or, indeed, a lifetime of indwelling urethral catheterization.

Temporary stents are tubular devices that are made of either a non absorbable or a biodegradable
material.
Spiral Stents
First-Generation Stents. The Urospiral (Porges) and the Prosta Kath (Pharma-Plast) are
examples of spiral stents. Complications included haematuria with clot retention (5%),
stent migration (15%), recurrent urinary tract infections (10%), and encrustation (4%).
Second-Generation Stents. Other spiral stents have been developed as second-generation models in
an attempt to overcome the problems of the first-generation stents just described while maintaining
the efficacy and ease of insertion. These are the Memokath and the Prosta Coil
Polyurethane stents: Are also known as intraurethral catheters. There are three types: the
intraurethral catheter, the Barnes stent, and the trestle stent.
Biodegradable Stents: Do not need to be removed, and eventually they disappear by
biodegrading .

Permanent Stents: Examples are Urolume &Memotherm.

UroLume is a woven tubular mesh that maintains its position in the urethra by outward external pressure.
Memotherm is a stent of nickeltitanium alloy that is expandable to 42 Fr with heat.
Temporary stents are receiving widespread attention, but the original idea that they should be
used as a temporary expedient to overcome outflow problems in the medically unfit population is
being modified. The newer stents, whether biodegradable or not, are being viewed as possible
methods of overcoming the temporary retention that can occur secondary to treatments such as
laser therapy or high-energy TUMT.

TRANSURETHRAL NEEDLE ABLATION OF THE PROSTATE (TUNA)

Heat treatment of whatever kind to the prostate is intended to reduce outflow resistance and the volume of
the obstruction by increasing the temperature within the prostate and inducing necrosis of prostatic tissue.
The aim is to increase prostatic temperature to in excess of 60° C. Transurethral needle ablation of the
prostate (TUNA) uses low-level radiofrequency (RF) energy that is delivered by needles into the prostate and
that produces localized necrotic lesions in the hyperplastic tissue. The generator produces a monopolar RF
signal of 490 kHz, which allows excellent penetration and uniform tissue distribution.
RF, however, has a much hotter central area with a very quick decline in temperature as the distance
increases from the treatment needle. This results in faster generation of the necrotic lesion but of a
smaller area.The patient most likely to benefit from TUNA would be one who had lateral lobe
enlargement and a prostate of 60 g or less. An average improvement in the mean symptom score of
13.1 symptom units and in the mean PFR of 6 mL/sec to be expected at 12 months.

Adverse Effects
By far the most common complication reported, however, is posttreatment urinary retention,
occurring at a rate between 13.3% and 41.6%. The second most common adverse event reported
is that of irritative voiding symptoms, (40%), Urinary tract infection to (3.1%).
Sexual dysfunction is rare after TUNA. Urinary incontinence has not been reported in any series.

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TRANSURETHRAL MICROWAVE THERAPY
The current transurethral method has developed from the early transrectal devices that supplied
heat ranging from 42° C to 44° C. The results with this early form of treatment were rather
disappointing, and transurethral catheters were developed that would allow higher temperatures
to be used while cooling the urethral mucosa. In one of these devices currently used, the
Prostatron, the cooling fluid in the catheter maintains the urethral temperature at about 44° C or
lower while producing temperatures within the prostate of up to 70° C
The two most commonly machines used are the Prostatron and the Targis.
Method of Action
Tissue exposed to a minimum of 45° C for about 60 minutes suffered hemorrhagic necrosis
with uniform extirpation
Thermal damage to the adrenergic fibers
Induction of Apoptosis
The very definite conclusion that TURP produce greater improvement in symptom scores and PFR
and that fewer men require re-treatment for BPH than with TUMT. It is clear that TUMT does not
outperform TURP.
LASERS (light amplification by the stimulated emission of radiation.)
In the laser, a flash lamp gives out high-intensity light, which then bombards a resonator cavity with
photons. These excite electrons in the resonator cavity to higher energy status. Most of the photons that
come from the flash lamp to the resonator cavity are wasted in the form of heat, with less than 5% being
absorbed. For this reason, lasers used in the treatment of BPH require rather elaborate cooling devices.
There are two ways in which lasers can have an effect on the prostate, either by coagulation or by
vaporization.
Therefore the factors determining whether coagulation or vaporization occurs are essentially the
power density of the laser beam itself, the total energy delivered, and the time for which it is
applied. Neodymium: Yttrium-Aluminum-Garnet Laser(wavelength of 1064 nm):
Its active medium consists of neodymium atoms in an yttrium-aluminum-garnet rod.This poor
absorption in a fluid medium causes thermal coagulation of the surface tissue and of areas just
under the surface. The Nd : YAG laser is a relatively inefficient way to do prostatectomy because
of the high power required.
Potassium-Titanyl-Phosphate Laser(532-nm wavelength):
This provides an intermediate level of coagulation and vaporization.
Only half the depth of tissue penetration is reached compared with that of the Nd : YAG laser.
Photo selective vaporization of the prostate (PVP) using a highpower 80-W KTP laser (Greenlight
PV Laser System) has produced an alternative laser technology seen by many as an exciting new
advance. KTP/532 laser energy is delivered by a side-firing glass fiber through a 27-Fr
continuousflow resectoscope. Sterile water irrigation is used, and the procedure is performed
with the use of spinal anesthesia. The end point of the procedure is the production of a TURP-like
cavity that has resulted from complete vaporization of the prostatic adenoma.
The laser technique was associated with highly significantly decreased bleeding with larger
coagulation zones. This technique can be used in patients who are on anticoagulant therapy or
who have severe bleeding disorder.
Holmium : Yttrium-Aluminum-Garnet Laser(2100 nm wavelength):
The energy is emitted in a series of rapid pulses is unlike the continuous wave of the Nd : YAG or
KTP lasers. Because it produces a cutting effect by vaporization of the tissue water, its
hemostatic properties are less than those of the continuous wave lasers.The Ho: YAG laser beam
is absorbed by water (unlike the Nd : YAG beam) at a wavelength of 2140 nm and causes
considerable tissue vaporization.This type of treatment can also be applied to large prostates.
Diode Laser
With conventional lasers, less than 5% of the electrical input is converted into laser light. The high
gain of the diode laser allows the more efficient use of the photons that are generated, decreasing
the size of the machine.
TRANSURETHRAL RESECTION OF THE PROSTATE (McCarthy)
Gold standard for the surgical management of BPH.
It was the BPH Guideline Panel’s recommendation that patients with minimal symptoms should undergo
watchful waiting and that if intervention was to be considered in patients who were more symptomatic the
patient should be informed of the harms and benefits of each therapeutic modality and participate actively in
making the decision, not only whether to intervene but which treatment modality would be his choice.

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The most common reasons for recommending intervention in a patient with symptoms of BOO
and irritability are that the symptoms are moderate to severe, bothersome, and interfere with the
patient’s quality of life.
Although symptoms constitute the primary reason for recommending intervention, in patients
with an obstructing prostate there are some absolute indications. These are acute urinary
retention, recurrent infection, recurrent hematuria, and azotemia.
The size of the prostate might be important in selecting what type of surgical therapy would be
warranted.Cystoscopy as a diagnostic procedure, is not recommended. To know the size of the
prostate TRUS is more precise than cystoscopy. Upper tract imaging is also not recommended to
be performed routinely. Rather, it should be reserved for patients with hematuria or renal
insufficiency or for those with a history of urinary infection, urinary tract surgery, or stones.
Perioperative Antibiotics
Prophylactic use of antibiotics, usually a single dose just before the start of surgery, has become
the norm. In patients who have preoperative bacteriuria or a catheter in situ before surgery, the
antibiotics should be continued until the catheter at time of surgery is removed. It is
recommended that patients should be given a first-generation cephalosporin in combination with
gentamicin before the initiation of surgery.
Traditionally, TURP has been performed using monopolar technology with 1.5% glycine or
mannitol as nonhemolytic fluids for irrigation. concerns about TUR syndrome have led to the
introduction of bipolar TURP.
Bipolar resection that is known as Gyrus Plasma Kinetic System. . The Gyrus bipolar system consists
of a generator with 200-W capability, an RF range of 320 to 450 kHz, Every surgical technique employs
the principle that the resection should be performed in a routine stepby-step manner.

Management of Intraoperative Problems

Hemostasis
Arterial bleeding is controlled by electro coagulation. After the catheter is inserted, at the end of
the surgical procedure, the irrigation fluid should be light pink. If the irrigation fluid has a
continued red color, one should suspect arterial bleeding. The surgeon should reinsert the
resectoscope and coagulate the Arterial bleeding.
Venous bleeding is apparent at the end of the procedure, when on irrigating the catheter the
return is initially clear but then dark blood later oozes from the catheter. Venous bleeding can be
controlled by filling the bladder with 100 mL of irrigating fluid and placing the catheter on traction
for 7 minutes at the operating table. The balloon of the catheter is overinflated to 50 mL of fluid.
Extravasation, or perforation of the prostatic capsule, occurs in about 2% of patients. The symptoms of
extravasation are restlessness, nausea, vomiting, and abdominal pain, despite spinal anesthesia. Pain
is usually localized to the lower abdomen and back. If extravasation is suspected, the operation should
be terminated as rapidly as possible but hemostasis must be secured. Bleeding must be controlled,
even as the extravasation is increased, because simultaneous postoperative management of
extravasation and hemorrhage is difficult. Over 90% of these patients can be managed simply by
urethral catheter drainage and cessation of the operative procedure
Transurethral Resection Syndrome
TUR syndrome occurs in 2% of the patients. The syndrome is characterized by mental confusion,
nausea, vomiting, hypertension, bradycardia, and visual disturbance. Usually, the patients do not
become symptomatic until the serum sodium concentration reaches 125 mEq/dL. The risk is
increased if the gland is larger than 45 g and the resection time is longer than 90 minutes.
Amount of fluid absorbed were dependent on the height of the fluid by the patient. This could not
be achieved when the fluid level was below 60 cm H2O.
Glycine is metabolized to glycolic acid and ammonium. Ammonium intoxication has been suggested as a
possible cause of the TUR syndrome or direct toxic effect of the glycine. Nevertheless, it is our belief that the
TUR syndrome is secondary to dilutional hyponatremia. Certainly, the syndrome can be reduced by the
administration of 3% saline solution. This can be corrected by giving the patient 200 mL of 3% saline solution
very slowly In patients who have a large gland or when the operating time is being prolonged, a serum
sodium value is routinely obtained, although the patient is still undergoing surgery. When patients
demonstrate a drop in serum sodium level, diuretics e.g., furosemide [Lasix]) are administered.
Intraoperative Priapism
This has usually been managed by injecting an α-adrenergic agent directly into the corpora
cavernosa. The solution of ephedrine or phenylephrine is usually diluted (e.g., 0.3 mL 1%
phenylephrine diluted to 3 mL with normal saline solution for 100 µg/1 mL).

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Chance of improvement of patients’ symptoms after TURP is significantly better than with less
invasive procedures. The most common complications in the immediate postoperative period are
failing to void (6.5%), bleeding requiring transfusion (3.9%), and clot retention (3.3%).Outcomes of
surgery were best for the men who were most bothered by urinary symptoms at baseline.

TRANSURETHRAL VAPORIZATION OF THE PROSTATE(TUVP)

With TUVP, two electrosurgical effects are combined: vaporization and desiccation. Vaporization
steams tissue away using high heat, and coagulation uses lower heat to dry out tissue.
Vaporization occurs at the leading edge and desiccation occurs at the trailing edge. For TUVP, the
cutting current power should be set to a maximum of 75% higher power than for a standard TURP.
Efficacy appears similar to that of TURP, but the studies are short-term evaluations and the
glands operated on are relatively small. The short-term complication profile appears to be better
than with TURP, but further studies are required to prove this because there is a certain variability
in the rate of occurrence of some of them.

TRANSURETHRAL INCISION OF THE PROSTATE

TUIP is effective in treating patients with LUTS caused by BOO. It has been shown to have an
important role in the management of younger patients, especially if the prostate is smaller than 30
g. The efficacy is comparable in such patients with TURP, and the results are maintained in the
long term. The technique is simple, and the morbidity is low.
With a Collings knife, an incision is made at the 5- and 7-o’clock positions or on one side of the midline
only. It starts just distal to the ureteral orifice and ends just proximal to the verumontanum.
There are some other approaches like Water-Induced Thermotherapy, Transurethral Ethanol
Ablation of the Prostate, Rotoresection of the Prostate,HIFU. . There is no significant evidence
available to support any of these as having a future in the treatment of symptomatic BPH.

OPEN PROSTATECTOMY
For larger prostate glands, open prostatectomy has been frequently performed. Recently holmium
laser enucleation of the prostate (HoLEP) with the holmium : yttrium-aluminumgarnet (Ho : YAG)
laser has been performed as a minimally invasive alternative to open surgery.
A cystoscopic examination is not indicated in the routine evaluation of a patient with obstructive
voiding symptoms. However, cystoscopy should be performed in men with hematuria, suspected
urethral stricture, and bladder calculus or diverticulum. It also can be helpful in confirming the
presence of a large median lobe or in assessing the length of the prostatic urethra.
When compared with TURP, open prostatectomy offers the advantages of lower re-treatment rate
and more complete removal of the prostatic adenoma under direct vision and avoids the risk of
dilutional hyponatremia (the TUR syndrome) that occurs in approximately 2% of TURP.
The disadvantages of open prostatectomy, as compared with TURP, include the need for a lower
midline incision and a resultant longer hospitalization and convalescence period. There also may
be an increased potential for perioperative hemorrhage.
Indications For Open Prostatectomy
The indications for prostatectomy, by either open approach or transurethral resection, include (1)
acute urinary retention; (2) recurrent or persistent urinary tract infections; (3) significant
symptoms from bladder outlet obstruction not responsive to medical therapy; (4) recurrent gross
hematuria of prostatic origin; (5) pathophysiologic changes of the kidneys, ureters, or bladder
secondary to prostatic obstruction; and (6) bladder calculi secondary to obstruction.

Open prostatectomy should be considered when the obstructive tissue is estimated to weigh more
than 75 g. If sizable bladder diverticula justify removal, suprapubic prostatectomy and diverticulectomy
should be performed concurrently. If the prostatectomy is performed without the diverticulectomy,
incomplete emptying of the bladder diverticulum and subsequent, persistent infection may occur.
Large bladder calculi that are not amenable to easy transurethral fragmentation may also be removed
during the open procedure. Open prostatectomy should also be considered when a patient presents
with ankylosis of the hip or other orthopedic conditions that prevent proper positioning for TURP. Also,
it may be wise to perform an open prostatectomy in men with recurrent or complex urethral conditions,
such as urethral stricture or previous hypospadias repair, to avoid the urethral trauma associated with
TURP. Finally, the association of an inguinal hernia with an enlarged prostate suggests an open
procedure, because the hernia may be repaired via the same lower abdominal incision .

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Contraindications to open prostatectomy include a small fibrous gland, the presence of prostate
cancer, and previous prostatectomy or pelvic surgery that may obliterate access to the prostate gland.
Potential risks include urinary incontinence, erectile dysfunction, retrograde ejaculation, urinary tract
infection, bladder neck contracture, urethral stricture, and the need for a blood transfusion. Other
potential untoward effects include deep vein thrombosis and pulmonary embolus.
Retropubic prostatectomy (Millin)
Enucleation of the hyperplastic prostatic adenoma is achieved through a direct incision of the anterior
prostatic capsule. Before proceeding with enucleation of the prostatic adenoma it is important to achieve
complete control of the dorsal vein complex as well as the lateral pedicles at the bladder neck (the main
arterial blood supply to the prostate gland).A figure of eight sutureis placed through the prostatovesicular
junction just above the level of the seminal vesicles to control the main arterial supply to the prostate gland.
When placing this suture, care must be taken to avoid entrapment of the neurovascular bundles located
posteriorly and slightly laterally. The index finger is then used to fracture the urethral mucosa at the level of
the verumontanum. With this maneuver, extreme care is taken not to injure the external sphincteric
mechanism. If hemorrhage is persistent, 4-0 chromic catgut suture can be used to place a figure of eight
suture in the bladder neck at the 5- and 7-o’clock positions as in suprapubic prostatectomy. When placing
these sutures it is necessary to visualize the ureteral orifices so that they are not incorporated.The
advantages of this procedure over the suprapubic approach are (1) excellent anatomic exposure of the
prostate, (2) direct visualization of the prostatic adenoma during enucleation to ensure complete removal, (3)
precise transection of the urethra distally to preserve urinary continence, (4) clear and immediate
visualization of the prostatic fossa after enucleation to control bleeding, and (5) minimal to no surgical
trauma to the urinary bladder. The disadvantage of the retropubic approach, as compared with the
suprapubic prostatectomy, is that direct access to the bladder is not achieved.
Suprapubic Prostatectomy/Transvesical (Freyer)
Enucleation of the hyperplastic prostatic adenoma through an extraperitoneal incision of the
lower anterior bladder wall. An electrocautery is used to create a circular incision in the bladder
mucosa distal to the trigone. Two figure-of-eight sutures used to advance the bladder mucosa
into the prostatic fossa at the 5-o’clock and 7-o’clock positions at the prostatovesical junction to
ensure control of the main arterial blood supply to the prostate .
This operation is ideally suited for patients with (1) a large median lobe protruding into the bladder, (2)
a clinically significant bladder diverticulum, or (3) large bladder calculi. It also may be preferable for
obese men, in whom it is difficult to gain direct access to the prostatic capsule and dorsal vein
complex . The disadvantage, as compared with the retropubic approach, is that direct visualization of
the apical prostatic adenoma is reduced. As a result, the apical enucleation is less precise and this
factor may affect postoperative urinary continence. Furthermore, hemostasis may be more difficult
because of inadequate visualization of the entire prostatic fossa after enucleation.
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Kobayashi S, Tang R, Shapiro E et al: Characterization and localization of prostatic alpha 1 adrenoceptors using
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study. J Urol 2008; 179: 616.
Kirby R, Roehrborn C, Boyle P et al: Efficacy and tolerability of doxazosin and finasteride, alone or in combination, in
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NURA: National Urology Research Agenda: American Urological Assocation Foundation, 2010

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 BURN MANAGEMENT AND SKIN GRAFTING
-Dr. PS Bhandari

A burn is an injury caused by thermal, chemical, electrical or radiation energy. A scald is a burn
caused by contact with a hot liquid or steam but the term 'burn' is often used to include scalds. A
burn can be caused by thermal, chemical, electrical or radiation energy. Thermal energy is the
most common cause of burn injury. Common sources of thermal burns are flame, steam, scald,
and contact with hot objects or surfaces. Inhalation injury is a type thermal injury caused by
superheated gases that enter the airway when burn victims are injured in an enclosed space.
As soon as the patient is brought to the hospital, assessment for airway, breathing, circulation,
disability, exposure (prevent hypothermia), conscious level, severity of burns and the need for fluid
resuscitation is done. Establish the cause and mechanism of injury i.e. fire, chemical burns, exposure
to ionizing radiation, high-pressure steam injury, high-tension electrical injury. Assess for associated
injuries: associated injuries may be sustained while the victim attempts to escape the fire. Explosions
or electricity may have thrown the patient some distance and result in internal injuries or fractures. It is
essential that the time of the burn injury be established. Burns sustained within an enclosed space
suggest possible inhalation injury. Pre-existing illnesses, drug therapy, allergies and drug sensitivities
are also important. Establish the patient's tetanus immunization status.
EXTENT OF BURN:After a routine examination, IV fluid is administered. Following initial
stabilization, the patient is taken to the dressing room for evaluation of extent of burn. The
“Wallace rule of 9’s” is commonly used to estimate the burned surface area in adults. The body is
divided into anatomical regions that represent 9% (or multiples of 9%) of the total body surface.
Head & Neck-9%, each upper extremity 9%, anterior trunk 18% (upper-9%,low9%), posterior trunk
18%,(upper-9%,low9%), each lower extremity 18% (ant-9% ,post-9%) and genitals1%
The ‘Rule of 9’s’ method is too imprecise for estimating the burned surface area in children because
the infant or young child’s head and lower extremities represent different proportions of surface area
than in an adult. Either Broader and Lunds classification or rule of 5is used to estimate the percentage
of burn in children. According to rule of 5, head-20%, front of trunk 20%, back of trunk 20% and each
limb 10%.The outstretched palm and fingers approximates to 1% of the body surface area. • Morbidity
and mortality rises with increasing burned surface area. It also rises with increasing age so that even
small burns may be fatal in elderly people. Burns greater than 15% in an adult, greater than 10% in a
child,or any burn occurring in the very young or elderly are serious.

Wallace rule of 9 Broader and Lunds Chart for estimation of burn

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Depth of burn
It is important to estimate the depth of the burn to assess its severity and to plan future wound
care. According to the depth of burn burns can be divided into three types: I degree, 2nd degree
(partial thickness burn-two types superficial and deep) and 3rd degree/ full thickness burn
I degree- Involves epidermis only. There is erythema mild pain, swelling but no blister formation .It
heals in 3-5 days.
2degree-Superficial Partial Thickness Burn: It involves, epidermis and papillary layer of dermis
There is severe pain, hyperesthesia and blister formation.
2degree-Deep Partial Thickness Burn: It involves epidermis, papilary dermis and part of reticular
dermis but skin appendages left behind .It is waxy white in color, soft and elastic in touch. It heals
in 3-4 weeks by hypertrophic scarring.
3rd degree/ full thickness burn: Entire thickness of skin is burnt. Burnt skin is tough, dry, inelastic,
looks like translucent parchment like eschar. Eschar is painless. It separate in 3-4 weeks of time
leaving granulation tissue. It does not heal of its own and requires grafting. It is common to find
all three types of burn within the same burn wound and the depth may change with time,
especially if infection occurs. Serious burn requiring hospitalization - Greater than 15% burns in
an adult, greater than 10% burns in a child, any burn in the very young, the elderly, burns of
special regions: face, hands, feet, perineum, circumferential burns, inhalation injury and
associated trauma or significant pre-burn illness: e.g. diabetes. Pathophysiology of burn shock
In a burn, tissue injury results from coagulation of cellular protein in response to heat produced by
thermal, chemical, electrical, or radiation energy. The depth of coagulative necrosis of the tissue
depends on the heat generated by the causative agent and the length of contact with the tissues.
Burn wounds can be conceptualized as having three zones representing damage to the tissues
resulting from transfer of heat. The central zone of coagulation is an area of irreversible tissue
necrosis, or full-thickness burn. Immediately surrounding the necrotic zone is the zone of stasis,
characterized by impaired blood flow. This zone may not show areas of coagulation initially but
may progress to tissue necrosis if adequate tissue perfusion is not restored to the area during the
resuscitation period. The zone of stasis is the area of greatest concern because this area can
convert to a deeper wound, creating a larger burn injury and loss of tissue. The outer zone of
hyperemia has sustained minimal tissue injury and usually heals rapidly.
In major burn injuries inflammatory mediators (e.g. histamine, prostaglandins, thromboxane, and nitric
oxide) are released in the circulation that increase capillary permeability and lead to localized burn wound
edema. This occurs within minutes to hours after injury. Increase in transcapillary permeability results in a
rapid transfer of water, inorganic solutes, and plasma proteins between the intravascular and interstitial
spaces. Subsequently, intravascular hypovolemia and haemoconcentration develop and maximum levels are
reached within 12 hours after injury. The steady intravascular fluid loss due to these sequences of events
requires sustained replacement of intravascular volume in order to prevent end-organ hypo perfusion and
ischemia. The reduction in cardiac output is the combined result of decreased plasma volume, increased
after load and decreased cardiac contractility, induced by circulating mediators. Appropriate fluid
management plays a fundamental role in management of burn shock.
FLUID MANAGEMENT
Burn injuries of less than 15% burns in an adult and less than 10% burns in a child , are associated with
minimal fluid shifts and can generally be resuscitated with oral hydration, except in cases of facial, hand and
genital burns. For extensive burns, many formulas have been described for resuscitation of shock.

Parkland formula
Initial 24 hours: Ringer’s lactated (RL) solution 4 ml/kg/% burn for adults and 3 ml/kg/% burn
for children. RL solution is added for maintenance for children:
4 ml/kg/hour for children weighing 0–10 kg
40 ml/hour +2 ml/hour for children weighing 10–20 kg
60 ml/hour + 1 ml/kg/hour for children weighing 20 kg or higher

Next 24 hours: Colloids given as 20–60% of calculated plasma volume. No crystalloids. Glucose in water
is added in amounts required to maintain a urinary output of 0.5–1 ml/hour in adults and
1 ml/hour in children.

Initial 24 hours: RL 4 ml/kg/% burn (adults)

Next 24 hours: Begin colloid infusion of 5% albumin 0.3–1 ml/kg/% burn/16 per hour

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 Brooke formula
Initial 24 hours: RL solution 1.5 ml/kg/% burn plus colloids 0.5 ml/kg/% burn plus
2000 ml glucose in water
Next 24 hours: RL 0.5 ml/kg/% burn, colloids 0.25 ml/kg/% burn and the same
amount of glucose in water as in the first 24 hours

Modified Brooke
Initial 24 hours: No colloids. RL solution 2 ml/kg/% burn in adults and 3 ml/kg/%
burn in children
Next 24 hours: Colloids at 0.3–0.5 ml/kg/% burn and no crystalloids are given. Glucose
in water is added in the amounts required to maintain good urinary output.

Evans formula (1952)

First 24 hours: Crystalloids 1 ml/kg/% burn plus colloids at 1 ml/kg/% burn plus
2000 ml glucose in water
Next 24 hours: Crystalloids at 0.5 ml/kg/% burn, colloids at 0.5 ml/kg/% burn
and the same amount of glucose in water as in the first 24 hours

Monafo formula
Monafo recommends using a solution containing 250 mEq Na, 150 mEq lactate and 100 mEq Cl.
The amount is adjusted according to the urine output. In the following 24 hours, the solution is
titrated with 1/3 normal saline according to urinary output.
Formulas developed for children
The formulas developed for children[35] are as follows.
Shriner’s cincinnati
Initial 24 hours:
a. For older children:
Lactated Ringer’s (RL) solution 4 ml/kg/% burn +1500 ml/m2 total (1/2 of total volume over 8
hours, rest of the total volume during the following 16 hours)
For younger children:
4 ml/kg/% burn +1500 ml/m2 total, in the first 8
hours RL solution + 50 mEq NaHCO3 RL solution
in the second 8 hours
5% albumin in LR solution in the third 8 hours

Galveston
Initial 24 hours: RL 5000 ml/m2 burn + 2000 ml/m2 total (1/2 of total volume over 8 hours, rest of
the total volume in 16 hours)
The most commonly used fluid for burn resuscitation is Parkland formula. All resuscitation formulas
are meant to serve as guides only. Consequently, fluid management in major burns should be
monitored using clinical and laboratory parameters. In severe burns, if peripheral intravenous access
cannot be achieved, central venous catheterization or surgical vascular access must be considered.
After the venous line is in place, a urinary catheter should be inserted to control and monitor the
patient’s fluid balance. Hypotension is a late finding in burn shock; so, pulse rate is a much more
sensitive monitoring parameter than arterial blood pressure. Fluid shifts are rapid during the early
period of burn shock (24–72 hours); so, serial determinations of haematocrit, serum electrolytes,
osmolality, calcium, glucose, and albumin are essential to help determine the appropriate method of
fluid replacement. The best single indicator is the urine output on an hourly basis.
Pain and anxiety medications. Patient is given intravenous analgesics to alleviate
pain. Burn wound management
The goal is to heal burn wound at the earliest
Partial thickness burns heals spontaneously
Small full thickness burns heals by wound contraction-contractures-should be avoided
Large FTB do not heal for long time-infection-septicemia-death. All full thickness burns
will require skin grafing to close the wound.
There are two approaches for burn wound management 1.Conservative approach which includes
open method and close method 2.Surgical approach
Conservative approach (close method) -- It prevents trauma to regenerating epithelium and
provides moist environment for faster healing .It is comfortable for patients.

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Splintage can be given to the patients if required. Smaller than 1cm in diameter (or smaller than the
patients little finger nail) should be left intact to minimize the risk of infection. Larger blisters or those
in an awkward position (in danger of bursting) should be aspirated under aseptic technique.Burn area
is cleaned with savlonand saline Burn area is made dry with gauze. Appropriate antimicrobial
cream/ointment is applied over the burn wound.Over this single layer of non-adherent vaseline gauze,
multiple Layer of meshed gauze and gamgee pads are applied. They are kept in place with the help of
compression dressing. Topical anti-microbial therapy is required because the systemic antibiotic may
not reach the target due to poor vascularity of burn wound due to hypovolaemia, haemo concentration,
thrombosis of vessels .Topical antimicrobials for the prevention and treatment of burn wound infection
includes mafenideacetate, silver sulfadiazine, silver nitrate solution, and silver-impregnated dressings.
These various therapies differ in their ability to penetrate eschars, antimicrobial activities, and adverse-
event profiles. If necessary, debridement, escharotomy, and fasciotomy are also preformed. Superficial
and deep partial thickness burns will heal with dressing only. Deep burns will require split skin grafting
after 3-4 weeks of burn.
Surgical approach --The goal is to achieve early closure of burn wound by early excision of devitalized
burn tissue and skin grafting thus reducing the infection risk and length of hospital stay. Early excision
until the fifth day after the accident should be used mainly for burns of the hand, deep second degree
burns of up to 10% of the body surface, deep second degree burns over the joints and deep second
degree burns of the neck. If no auto grafts are available homografts or grafts from animals are used.
Diet
After a severe burn injury, a prolonged and persistent hypermetabolic response has been noted
(believed to be secondary to elevation of catecholamines, cortisol, and inflammatory mediators). This
response augments the metabolic rate, leading to muscle catabolism and immunosuppression.
The loss of body mass associated with severe burns has been associated with higher infection
rates, delayed wound healing, and longer hospital stays; therefore, the initiation of early and
aggressive nutritional support is required. To manage the postburnhypermetabolic state and its
complications, enteral nutrition is a safe, widely available, and effective measure that should be
started within the first 24 hours of admission.
SKIN GRAFT
A skin graft is a piece of skin (epidermis and dermis) which is completely separated from the body
and transplanted onto another site from where it regains its blood supply.

Types of Skin Graft

On the basis of their origin, a skin graft may be one of the following:
Autograft: A skin graft transferred from one part of the body to another in the same
individual is called an autograft. An isograft is a graft between two genetically identical
individuals such as identical twins and behaves like an autograft.
Allograft (homograft): A graft transferred from one individual to another of the same
species. This will “take” (see later) exactly like an autograft and survive temporarily but
will ultimately get rejected.
Xenograft (heterograft): A graft transferred fromone species to another, e.g., pig to
humans. This graft will never “take” and act as temporary skin substitute only.

On the basis of their dermal content, a skin graft may be:

Partial-thickness skin graft (split-thickness skin grafts, STSG or SSG): These grafts consist of
whole of epidermis and part of dermis. They have been further classified into thin,
intermediate, and thick split thickness skin grafts depending on the amount dermis included.
Full-thickness skin graft (FTSG or FTG): They have the full component of epidermis and
dermis. They are also known as Wolff–Krause grafts.
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Gibran NS, Heimbach DM. Current status of burn wound pathophysiology. ClinPlast Surg. 2000;27:11–22.
Scott JR, Muangman PR, Tamura RN, Zhu KQ, Liang Z, Anthony J, et al. Substance P levels and neutral endopeptidase
activity in acute burn wounds and hypertrophic scar. PlastReconstr Surg. 2005;115:095–102.
Berger MM. Antioxidant micronutrients in major trauma and burns: Evidence and practice. NutrClinPract. 2006;21:438–49.
Crimi E, Sica V, Williams-Ignarro S, Zhang H, Slutsky AS, Ignarro LJ, et al. The role of oxidative stress in adult critical
care. Free RadicBiol Med. 2006;40:398–406.
Heyland DK, Dhaliwal R, Day AG, Muscedere J, Drover J, Suchner U, et al. Reducing deaths due to oxidative stress (The
REDOXS Study): Rationale and study design for a randomized trial of glutamine and antioxidant supplementation in
critically-ill patients. ProcNutr Soc. 2006;65:250–63.
Moore FD. The body-weight burn budget.Basic fluid therapy for the early burn.SurgClin North Am. 1970;50:1249–65.
Underhill F. The significance of anhydremia in extensive surface burn.JAMA. 1930;95:852–7.

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 Holm C, Mayr M, Tegeler J, Hörbrand F, Henckel von Donnersmarck G, Mühlbauer W, et al. A clinical randomized study
on the effects of invasive monitoring on burn shock resuscitation.Burns. 2004;30:798–807.
Cancio LC, Kramer GC, Hoskin SL. Gastrointestinal fluid resuscitation of thermally injured patients. J Burn Care and
Res. 2006;27:561–9.
Pham T, Cancio LC, Gibran NS. American Burn Association practice guidelines burn shock resuscitation. J Burn Care
and Res. 2008;29:257–66.
Alvarado R, Chung KK, Cancio LC, Wolf SE. Burn resuscitation. Burns. 2009;35:4–14.
Baker RH, Akhavani MA, Jallali N. Resuscitation of thermal injuries in the United Kingdom and Ireland. J
PlastReconstrAesthet Surg. 2007;60:682–5.
Fakhry SM, Alexander J, Smith D. Regional and Institutional variation in burn care. J Burn Care Rehabil. 1995;16:86–90.
Aynsley-Green A, McGann A, Deshpande S. Control of intermediary metabolism in childhood with special reference to
hypoglycaemia and growth hormone. ActaPaediatrScand Suppl. 1991;377:43–52.
Warden GD. Burn shock resuscitation. World J Surg. 1992;16:16–23.
Baxter C. Fluid volume and electrolyte changes in the early post-burn period. Clin Plastic Surg. 1974;1:693–703.
Pruitt BA. Fluid and electrolyte replacement in the burned patient.SurgClin North Am. 1978;58:1291–312.
Friedrich JB, Sullivan SR, Engrav LH, Round KA, Blayney CB, Carrougher GJ, et al. Is supra-Baxter resuscitation in
burn patients a new phenomenon? Burns. 2004;30:464–6.
Sullivan SR, Friedrich JB, Engrav LH, Round KA, Heimbach DM, Heckbert SR, et al. “Opioid creep” is real and may be
the cause of “fluid creep” Burns. 2004;30:583–90.
Pruitt BA. Protection from excessive resuscitation: “pushing the pendulum back.” J Trauma. 2000;49:567–8.
Fodor L, Fodor A, Ramon Y, Shoshani O, Rissin Y, Ullman Y. Controversies in fluid resuscitation for burn
management: Literature review and our experience. Injury Int J Care injured. 2006;37:374–9.
Baxter CR, Shires GT. Physiological response to crystalloid resuscitation of severe burns. Ann NY Acad Sci. 1969;150:874–94.
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Enoch S, Roshan A, Shah M; Emergency and early management of burns and scalds. BMJ. 2009 Apr 8 338:b1037. .
26.Papini R; Management of burn injuries of various depths. BMJ. 2004 Jul 17 329(7458):158-60

LAPAROSCOPIC GROIN HERNIA REPAIR

(TOTALLY EXTRA PERITONEAL REPAIR)
-Dr Trilok Chand

INTRODUCTION:
A hernia is the bulging of whole or a part of a viscous through the wall that contains it. The first groin
hernia surgery was done during the end of the 16th century. They involved hernia sac reduction and
resection and posterior wall reinforcement of the inguinal canal by approximating its muscular and
fascial components. The life time risk of developing inguinal hernia is 3% for women and 27% for men.
[1] Indirect inguinal hernia is the most common groin hernia. The direct inguinal hernias are less
common and femoral hernia account about 5 % of total groin hernia. Right side hernia is more common
than left. Inguinal hernias are almost always symptomatic; and the only cure is surgery. [2] A minority
of patients are asymptomatic but even a watch-and-wait approach in this group results in surgery in
approximately 70% within years. [2] Surgical treatment is successful in most of cases but recurrences
necessitate reoperations in 10-15% and long-term disability due to chronic pain (moderate pain lasting
longer than 3 months) occurs in 10-12% of patients. Approximately 1-3% of patients have severe
chronic pain. In the early 1980s, minimally-invasive techniques for groin hernia repair were first done
and reported on in the scientific literature, adding another management modality. Laparoscopic Trans
Abdominal Preperitoneal (TAPP) and Totally Extra Peritoneal (TEP) endoscopic techniques,
collectively, “laparo-endoscopic surgery,” have been developed as well.
Table 1: Current inguinal hernia repair techniques
Non-mesh techniques Shouldice
Bassini
Desarda
Open mesh techniques* Lichtenstein
Trans inguinal pre-peritoneal (TIPP)
Trans rectal pre-peritoneal (TREPP)
Plug and patch
Endoscopic techniques Totally extra-peritoneal (TEP)
Trans abdominal pre-peritoneal repair (TAPP)
Single incision laparoscopic repair (SILS)

RISK FACTORS FOR GROIN HERNIA:

Inheritance (first degree relatives diagnosed with IH elevates IH incidence, especially in
females)[3] Gender (IH repair is approximately 8-10 times more common in males)
Age (peak prevalence at 5 years, primarily indirect and 70-80 years, primarily direct)

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 Collagen metabolism (a diminished collagen type l/lll
ratio) Prostatectomy history (especially open radical) [4]
Obesity
Increased systemic levels of matrix metalloproteinase
Rare connective tissue disorders (e.g. Ehlers-Danlos
syndrome) Race (less common in black)
Chronic constipation
Tobacco use

CLINICAL FEATURES AND DIAGNOSTIC EVALUATION:

A reducible swelling with cough impulse in inguinal region is a definitive evidence of an inguinal hernia
and need no further evaluation except history and physical examination in case non-reducible vague
inguinal swellings always need further diagnostic evaluation. The role of ultrasonography in non-
reducible inguinal swelling confirmed by meta-analysis with a 96.6% sensitivity, 84.8% specificity and
positive predictive value of 92.6%.[5] For the diagnosis of occult groin hernias magnetic resonance
imaging was found to be superior to both ultrasonography and computerized tomography.

INDICATIONS FOR GROIN HERNIA REPAIR:

The goal of treatment is to improve symptoms and the quality of life, prevent adverse events such
as incarceration and strangulation, while keeping the surgical complication low. Surgery is
recommended for all symptomatic inguinal hernias. It can improve the quality of life of the
patients. In men watchful waiting can be done for asymptomatic non-progressive inguinal hernia.
There is a low complication risk (incarceration or strangulation) in asymptomatic or minimally
symptomatic men with inguinal hernias. Women should be operated in all case of primary inguinal
hernia because possibility of femoral hernia. In recurrent inguinal hernia the decisions for operation
depends on initial technique that is with or without mesh, symptom and associated co-morbidity.

METHODS OF INGUINAL HERNIA REPAIR:

Choosing the best or most suitable groin hernia repair technique is a true challenge. The best operative
technique should have the following attributes: low risk of complications (pain and recurrence), (relatively
easy to learn, fast recovery, reproducible results and cost effectiveness. In most situations, a mesh repair is
preferred. However, a minority of surgeons hold the opinion that mesh use should be avoided as much as
possible. Inguinal hernia can be repaired by either suture or mesh based techniques and either by open or
laparoscopic/endoscopic techniques. The open, suture based operations are perform through the classic
anterior approach. Minimally invasive techniques are always done through posterior approach. The well-
known suture based techniques are Bassini and Shouldice. The slandered mesh based techniques through
an anterior approach is that Lichtenstein. Shouldice repair is associated with lower recurrence rate than
other popular suture based techniques such as Bassini (7% vs. 4.3), but the recurrence rate of suture based
technique is four time higher than mesh based techniques (4% vs. 0. 9%).In world guideline for groin hernia
mesh based repair is recommended for the adult patients either the Lichtenstein procedure or laparoscopic/
endoscopic techniques as a standard for groin hernia repair (recommendation grade A). Adults from 18 – 30
also benefited from mesh based techniques and studies have shown that such technique have no effect on
male fertility. [6]

INDICATIONS OF LAPAROSCOPIC GROIN HERNIA REPAIR:

Unilateral can be treated either by open surgery or by endoscopy/ laparoscopic surgery. The
classic indications for endoscopic/laparoscopic groin hernia repair are-
Hernia in women
Bilateral inguinal hernia
Recurrent hernia after prior anterior approach.
CONTRAINDICATION:
There is no absolute contraindication to laparoscopic/ endoscopic hernia repair of groin hernia.
Patient not fit for general / regional anaesthesia in view of medical illness. Medical illness like
coagulopathy and intra abdomen infection/ascites, irreducible/strangulated hernia and giant
scrotal hernia are relative contraindications’ Lower midline incision, previous preperitoneal
surgery also are relative contraindication. Numerous studies have shown that endoscopic/
laparoscopic repair of inguinal hernia has advantage over conventional repair:

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 Advantages Disadvantages
1. Reduced post-operative pain. 1.Higer learning curve
2.Earlier return to work 2.Chance of injury to bladder/bowel
3.Less wound infection/ hematoma 3.Chance of injury to blood vessels.
4. Faster recovery

LAPAROSCOPIC ANATOMY OF GROIN HERNIA:

The knowledge of anatomy of groin region is essential for repair of groin hernia. Laparoscopic
repair is a rear strategy view requiring anatomical understanding from peritoneal surface to
outwards. For the better understanding, we can describe in the following headings.

Myopectineal Orifice of Fruchaud: in 1956 Henry Fruchaud

proposed that all groin hernia occurs in a single weak area
called the Myopectineal Orifice. The Myopectineal orifice, or
MPO, is bound superiorly by the arching fibres of the
transversus abdominis and internal oblique muscles, and
inferiorly by the pectineal line. The MPO is then composed by
two regions separated by the inguinal ligament; the
suprainguinal region, is the site for direct and indirect inguinal
hernias, and a small sub segment of the subinguinal region, is
the site for femoral hernias. Proper exposure of the area is
essential during a preperitoneal(posterior) repair.

THE EXTRAPERITONEAL SPACE:

Space of Bogros: The retroinguinal space (or Bogros' space) is the extraperitoneal space situated deep
to the inguinal ligament. It's limited by the fascia transversalis anteriorly, the peritoneum posteriorly
and the iliac fascia laterally. This preperitoneal space communicates with prevesical space of Retzius.
Space of Retzius: The preperitoneal space, medial to space of bogros,lies deep to supra vesical
and medial umblical fossa contains loose connecting tissue and fat. Contents include obturator
vessels and accessory pudendal vessels(10%).
Vascular space: Space between anterior and posterior laminae of the transversalis fascia. This includes the
aponeurosis of the transversus abdominis muscle. Contents includes inferior epigastric vessels.
The space of Bogros is located lateral to the space of Retzius. During laparoscopic inguinal hernia
repair, the space of Bogros is explored to access the iliac fossa as well as to make it easier to open the
lateral mesh and lay it flat. During surgery, after the preperitoneal retropubic space is separated, care
should be taken that the deep transverse abdominal fascia is tightly attached to the anterior abdominal
wall at the site lateral to the inferior epigastric blood vessels when separating the space of Bogros.
Thus, the deep transverse fascia should be incised at the attachment site to enter the space of Bogros.
Space of Retzius: The preperitoneal retropubic space is in the midline of the lower abdomen with the
superficial transverse fascia and the pubic bone anteriorly, the bladder posteriorly, the umbilicus level
superiorly, the pelvic floor muscles inferiorly, and the inferior epigastric arteries laterally. It is filled with
loose connective tissue and fat, obturator vessels and accessary pudendal vessels (10%). The space is
easily separated; the pubic symphysis and the shiny Cooper’s ligament are readily visible after slight blunt
separation. Usually, the preperitoneal retropubic space is equivalent to the space of Retzius. However, the
space of Retzius originally referred to the space formed by the fold of the tight fusion of the deep transverse
fascia and the peritoneum between the bladder and the peritoneum, which includes the bladder and is filled
with loose connective tissue. In fact, to obtain a more capacious preperitoneal retropubic space, the surgeon
needs to incise the deep transverse fascia that is attached to the pubic bone and Cooper’s inguinal ligament
and enter the visceral space. Therefore, the preperitoneal retropubic space should include the space of
Retzius, a part of the visceral space and a part of the parietal space.
PERITONEAL FOLDS:
Median umbilical ligament: It extends from the apex of the bladder to the umbilicus, on the deep
surface of the anterior abdominal wall. It represents obliterated urachus.
Medial umbilical ligament: It represent obliterated umbilical artery and can be traced down up to
internal iliac artery.
umbilical ligament Lateral: The lateral umbilical fold overlies the inferior epigastric artery and its
accompanying veins.
Lateral fossae: it is lateral to lateral umbilical ligament and site for indirect inguinal hernia.

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Medial fossae it occurs between lat eral and medial umbilical fold and it is site for direct nguinal
hernia. HASSELBACH’S TRIANGLE: it is bounded by medially lateral border of rectus abdominus
muscle, inferior epigastric vessels laterally and inguinal ligament inferiorly. Most direct inguinal
hernias come through it.
TRIANGLE OF DOOM: It is a trian gular area bound by the vas deferens, the testicul ar vessels and
the peritoneum fold. The medial border by vas deferens and lateral border by testicular vessels,
the free edge of peritoneum makes lower border. Within this triangle external iliac vessels, deep
circumflexiliac vein, femoral nerve and genital branch of genital femoral nerve.Fig (A).

TRIANGLE OF PAIN: The triangl e of pain (fig B) is a triangular area located lateral to the triangle of
doom and bound by the iliopubic tra ct, the testicular vessels and the peritoneal fold. This area from
lateral to medial includes the lateral femor al cutaneous nerve, the femoral branch of the genito femoral
nerve and the femoral nerve, which runs on the surface of the psoas muscle and the iliac muscle. Most
of these nerves pass through the deep surface of the iliopubic tract to innervate the corresp onding
area of the perineum and thigh. Clinical data h ave shown that the lateral femoral cutaneous nerv e and
the femoral branch of the genitofemoral nerve a re more commonly damaged.
CORONA MORTIS: The corona mortis is defined as the v ascular connection
between the obturator and the external iliac systems. [7]and may be venous,
arterial, or both. It is also called circle of death or crown of death. The pubic
branch f rom the inferior epigastric artery in 25-30% of peopl e is big and can be
replace the obturator artery (aberrant). It can encircle the neck of hernia sac and
be i njured in a femoral hernia repair. It might be injured while cleaning the
cooper’s by clearing it off areolar- adipose ligament. Venous corona mortis has
been rep orted in higher frequency than the arterial one. [8,9]

TECHINIQUE:
TOTALLY EXTRAPERITONEAL R EPAIR OF HERNIA(TEP):The patient is best posit ioned supine, with the
arms tucked and pressure points padded. Laparoscopic monitors are positioned at the foot of the table and
the surgeon opposite the side of the hernia to be worked on. General anaest hesia is preferable. it can be
done in regional anaesthesia also if the patient is not fit for general an aesthesia. Bladder catheterization can
be considered. Prophylactic antibiotic is given at the time of induction. The position of the surgeon is to the
opposite side of hernia. The head end of patient kept at 15* lo w. The contents of hernia if need to be
reduced. After painting and draping a transverse incision is made about 1.0 cm below to umbilical just lateral
to midline about 1.5 to 2.0 cm in size. Dissection is done up to anterior rectus sheath and a 1.0 cm transverse
incision made on the anterior rectus sheath. The rectus muscle is retracted laterally and a 10mm cann ula
inserted. Insufflation is done with carbon dioxid gas.
CREATION OF EXTRAPERITONEAL SPACE:
This can be done by balloon disse ction or by 0-degree scope. The pubic symphysis works as a
guide which is called as light house. Second 5.0 mm port is placed about 2.0 cm above to p ubic
symphysis in the mid line. Another 5.0 mm port is placed in midline in between the two ports
under vision. The picture is showing OR set up and position o f patient.
Dissections in extraperitoneal space are begun by dividing the loose aerolar tissue in the midline
using sharp and blunt dissection. The fir st landmark, the pubic bone, is identified - which appears
as a white glistening structure in the midline . The pubic bone is visualized and bared of all
connective tissue, creating a shelf extending about 2–3 cm in the retropubic space, which acts as
a shelf to place the mesh. Any inadvertent tears in the perito neum during dissection can produce
a loss of working space. The dissection is then traced laterally to wards the side of the hernia.

349
In case of direct hernia, the hernia sac is visualized going into the weakness in the Hasselbach's
triangle before the inferior epigastric vessels can be visualized. On the other hand, in the indirect
hernia, the inferior epigastric vessels are seen before the hernia sac is encountered. Once the
adhesions are lysed or hernia sac is reduced, as in direct hernia, the anatomical landmarks which now
become visible are Cooper's ligament, iliopubic tract, femoral canal and the inferior epigastric vessel.
The spermatic cord lies immediately inferior and lateral to the inferior epigastric vessels. The peritoneal
sac is a white glistening structure lying anterolateral to the cord. The sac is completely dissected off
the cord structures and reduced. In cases of complete hernia, attempt should not be made to
completely reduce the sac as excessive traction and dissection cause severe postoperative pain. The
sac should be transacted and ligated using a catgut end loop or by intracorporal sutures, leaving the
distal sac open in situ. The vas deferens is seen lying separately on the medial side and gonadal
vessels are seen on the lateral side forming a triangle. This triangle is known as ‘triangle of doom’.

Dissection is continued lateral to the cord structures to create adequate space for the placement of
mesh. The lateral space contains loose areolar tissue, which is completely divided using sharp and
blunt dissection. The psoas muscle is seen lying on the floor on which lateral cutaneous nerve of thigh
and genitofemoral nerve can be seen traversing. The lateral boundary of the dissection is marked by
the anterior superior iliac spine. After creating the lateral space adequately, the mesh is introduced
through the 10-mm sub umbilical port. The mesh is placed over the space created so that it covers the
sites of direct, indirect, femoral and obturator hernias. The mesh is then secured in place with the help
of fixation devices. After adequately spreading the mesh, which extends from the midline medially, to
lying over the psoas muscle on the lateral side, preperitoneal space is deflated.
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Fitzgibbons RJ, Ramanan B, Arya S, et al. Long-term results of a randomized controlled trial of a nonoperative strategy (watchful waiting)
for men with minimally symptomatic inguinal hernias. Ann Surg. 2013;258(3):508-15. doi:10.1097/SLA.0b013e3182a19725.
Liem MS, van der Graaf Y, Zwart RC, Geurts I, van Vroonhoven TJ. Risk factors for inguinal hernia in women: a case-
control study. The Coala Trial Group. Am J Epidemiol. 1997;146(9):721-26.
Nilsson H, Stranne J, Stattin P, Nordin P. Incidence of groin hernia repair after radical prostatectomy: a population-
based nationwide study. Ann Surg. 2014;259(6):1223-27. doi:10.1097/SLA.0b013e3182975c88.
Light D1, Ratnasingham K, Banerjee A, Cadwallader R, Uzzaman MM, Gopinath B. The role of ultrasound scan in the
diagnosis of occult inguinal hernias. Int J Surg. 2011;9(2):169-72. doi: 10.1016/j.ijsu.2010.10.014. Epub 2010 Nov 5.
Hallén M1, Westerdahl J, Nordin P, Gunnarsson U, Sandblom G. Mesh hernia repair and male infertility: a retrospective
register study. Surgery. 2012 Jan;151(1):94-8. doi: 10.1016/j.surg.2011.06.028. Epub 2011 Sep 22.
Moore KL, Dalley AF, Agur AM (2010) Clinically oriented anatomy. 6th edn, Lippincott Williams and Wilkins, Baltimore, J Anat 215:

Berberoglu M, Uz A, Ozmen MM, Bozkurt MC, Erkuran C, Taner S, Tekin A, Tekdemir I. Corona mortis: an anatomic study
in seven cadavers and an endoscopic study in 28 patients. Surg Endosc. 2001; 15: 72–75.
Tornetta P 3rd, Hochwald N, Levine R. Corona mortis. Incidence and location. Clin Orthop Relat Res. 1996; 329: 97–101.

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 RENAL STONES
-Dr. Pawan Lal, Dr. Mehul Agarwal

The incidence of urinary tract stones is increasing. According to National Health and Nutrition
Examination Survey 2012 10.6%of men and 7.1% women in US are affected by renal stone disease.
Stone disease affects men more commonly than women. Heat exposure and dehydration constitute
occupational risk factors for stone formation and also stones risk directly correlate with weight and
BMI although magnitude of association was greater in women than men.

Etiopathogenesis
Physical process of stone formation comprises a complex cascade of events that occurs as the
glomerular filtrate traverses the nephron. It begins with urine that becomes supersaturated with
respect to stone-forming salts, such that dissolved ions or molecules precipitate out of solution and
form crystals or nuclei. Once formed, crystals may flow out with the urine or become retained in the
kidney at anchoring sites that promote growth and aggregation, ultimately leading to stone formation.

Stage of Saturation
Pure aqueous solution of a salt is considered saturated when it reaches the point at which no further
added salt crystals will dissolve. The concentration product at the point of saturation is called the
thermodynamic solubility product (Ksp), which is the point at which the dissolved and crystalline
components are in equilibrium for a specific set of conditions. At this point addition of further crystals
to the saturated solution will cause the crystals to precipitate unless the conditions of the solution
such as pH or temperature are changed. In urine despite concentration products of stone-forming salt
components such as calcium oxalate that exceed the solubility product, crystallisation does not
necessarily occur because of the presence of inhibitors.As concentrations of the salt increase further
the point at which it can nolonger be held in solution is reached and crystals form. The concentration
product at this point is called the formation product (Kf). The solubility product and the formation
product differentiate the three major states of saturation in urine: undersaturated, meta-stable, and
unstable. It is in metastable state modulation of factors controlling stone formation can take place and
therapeutic intervention is directed.

Nucleation and Crystal Growth, Aggregation and Retention

Homogeneous nucleation is the process by which nuclei form in pure solution. Nuclei are the earliest
crystal structures that will not dissolve. Small nuclei are unstable below a critical size threshold
dissolution of the crystal is favoured over crystal growth. If the driving force (supersaturation level)
and the stability of the nuclei are adequate and the lag time to nucleation is sufficiently short
compared with the transit time of urine through the nephron, the nuclei will persist. Within the
timeframe of transit of urine through the nephron estimated at 5 to 7 minutes, crystals cannot grow to
reach a size sufficient to occlude the tubular lumen. However if enough nuclei form and grow,
aggregation of the crystals will form larger particles within minutes that can occlude the tubular lumen.
Although it was initially concluded that free particle stone formation was impossible within the normal
transit time through the nephron fixed particle theory was proposed. According to it an anchoring site
should be present to which crystals bind thereby prolonging the time the crystals are exposed to
supersaturated urine and facilitating crystal growth and aggregation(like oxalate induced injury to
renal epithelial cells.

Inhibitors and Promoters of Crystal Formation

The presence of molecules that raise the level of supersaturation needed to initiate crystal nucleation
or reduce the rate of crystal growth or aggregation prevents stone formation from occurring. Common
inhibitors include inorganic pyrophosphate, citrate, magnesium account for 20% of inhibitory activity of
whole urine. Polyanion macromolecules including glycosaminoglycans, acid mucopolysaccharides
and RNA have been shown to inhibit crystalnucleation and growth. Urinary glycoproteins nephrocalcin
and Tamm-Horsfall glycoprotein are potent inhibitors of calcium oxalate monohydrate crystal
aggregation. Osteopontin has been shown to inhibit nucleation growth and aggregation of calcium
oxalate crystals as well as to reduce binding of crystals to renal epithelial cells.

Types of Calculi
Calcium Calculi
Calcifications can occur and accumulate in the collecting system resulting in nephrolithiasis.
80% percent of all urinary stones are calcareous. Calcium nephrolithiasis is most commonly

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 due to elevated urinary calcium, elevated urinary uric acid, elevated urinary oxalate or a
decreased level of urinary citrate. Calcifications within the parenchyma of the kidney are
known as nephrocalcinosis, rarely cause symptoms however usually are not amenable to
traditional therapies appropriate for urinary stone disease. Nephrocalcinosis is frequently
encountered with renal tubular acidosis and hyperparathyroidism. Nephrolithiasis and
nephrocalcinosis frequently coexist.

Non Calcium Calculi

Struvite Calculi
Struvite stones are composed of magnesium, ammonium and phosphate (MAP). They
are found most commonly in women and may recur rapidly. They frequently present as
renal staghorn configured calculi and rarely present as obstructing ureteral stones except
after surgical intervention. Struvite stones are infection stones associated with urea-
splitting organisms including Proteus, Pseudomonas, Providencia, Klebsiella,
Staphylococci and Mycoplasma. The high ammonium concentration derived from the
urea-splitting organisms results in an alkaline urinary pH. Thus only at elevated urinary
pH (>7.19) MAP crystals precipitate. Foreign bodies and neurogenic bladders may
predispose patients to urinary infections and subsequent Struvite stones. Culture-specific
antibiotics can reduce urease levels and help reduce stone recurrence. Stone removal is
therapeutic.Long-term management is optimised with the removal of all foreign bodies,
including catheters of all varieties. A short ileal loop urinary diversion helps decrease the
risk of stones in those with supravesical urinary diversion.

Uric acid
Uric acid stones comprise <5% of all urinary calculi and are usually found in men.
Patients with gout, myeloproliferative diseases or rapid weight loss and those treated for
malignant conditions with cytotoxic drugs have an increased incidence of uric acid
stones.Patients present with a urinary pH consistently <5.5 contrast to patients with
hyperuricosuric calcium nephrolithiasis, who have a urinary pH >5.5. As the urinary pH
increases above the dissociation constant pKa of 5.75, it dissociates into a relatively
soluble urate ion. Treatment is centred on maintaining a urine volume>2 L/day and a
urinary pH >6.0. Reducing dietary purines or the administration of allopurinol also helps
reduce uric acid excretion. Alkalinization is the mainstay of therapy and may dissolve
calculi.

Cystine Calculi
Cystine lithiasis is secondary to an inborn error of metabolism resulting in abnormal
intestinal mucosal absorption and renal tubular absorption of dibasic amino acids like
cystine, ornithine, lysine and arginine.The solubility of cystine is pH dependent, with a pK
of approximately 8.1. There is no known inhibitor for cystine calculi and cystine stone
formation is completely dependent on excessive cystine excretion.Cystine stones are
frequently associated with calcium calculi and their related metabolic abnormalities. They
may present as single, multiple or staghorn configured stones. The diagnosis is
suspected in patients with a family history of urinary stones and the radiographic
appearance of a faintly opaque, ground-glass, smooth-edged stone. Urinalysis frequently
reveals hexagonal crystals. The stones have an amber colour and stone analysis
confirms the diagnosis. Medical therapy includes high fluid intake (>3 L/d day and night)
and urinary alkalinization. A low-methionine (precursor to cystine) diet has limited impact
as most of the cystine is endogenous and most of the ingested methionine is incorporated
into protein. Glutamine, ascorbic acid, and captopril are effective in some patients.
Penicillamine can reduce urinary cystine levels. It complexes with the amino acid and this
complex is dramatically more soluble. Mercaptopropionylglycine (Thiola), 300–1200 mg in
divided doses, with initial dosing matched with total quantitative cystine excretion forms a
soluble complex with cystine and can reduce stone formation and is the most commonly
used sulphide binding drug. Surgical treatment is similar to that for other stones except
that most stones are recalcitrant to extracorporeal shock wave lithotripsy (SWL).

Xanthine
Xanthine stones are secondary to a congenital deficiency of xanthine dehydrogenase.
Allopurinol used to treat hyperuricosuric calcium nephrolithiasis and uric acid lithiasis

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 produces iatrogenic xanthinuria. The stones are radiolucent and are tannish yellow in
colour. Treatment should be directed by symptoms and evidence of renal obstruction.
High fluid intake and urinary alkalinization are required for prophylaxis. If stones recur a
trial of allopurinol and a purine-restricted diet is appropriate.

Indinavir
Indinavir is the most common protease inhibitor that results in radiolucent stones in up to
6% of patients who are prescribed this medication. Indinavir calculi are the only urinary
stones to be radiolucent on non-contrast CT scans.
Temporary cessation of the medication with intravenous hydration frequently allows these
stones to pass. The stones are tannish red and usually fall apart during basket extraction.

Rare Stones
Silicate stones are very rare and are usually associated with long-term use of antacids
containing silica. Surgical treatment is similar to that of other calculi. Triamterene stones
are radiolucent and have been identified with an increased frequency. They are
associated with antihypertensive medications containing triamterene, such as Dyazide.
Discontinuing the medication eliminates stone recurrences. Other medications that may
become stone constituents include glafenine and antrafenine.

SYMPTOMS
Pain: Renal colic and non colicky renal pain are the two types of pain originating from the kidney.
Renal colic usually is caused by stretching of the collecting system or ureter whereas non-
colicky renal pain is caused by distention of the renal capsule. Symptoms of renal colic
depend on location of stone.
Hematuria: Patient may present with intermittent gross hematuria thus urine microscopy should
be routinely done.
Infection
Pyonephrosis
Obstructive calculi may result in the development of pyonephrosis.It is an extreme form of
infected hydronephrosis. Presentation is variable and may range from asymptomatic
bacteriuria to urosepsis. Bladder urine cultures may be negative. Renal urine aspiration is
the only way to make the definitive diagnosis.
Xanthogranulomatous pyelonephritis
Xanthogranulomatous pyelonephritis is associated with upper-tract obstruction and
infection.One-third of patients present with calculi two-thirds present with flank pain, fever
and chills. Fifty percent of patients present with persistent bacteriuria.
Nausea and Vomiting

RADIOLOGICAL INVESTIGATIONS
Computed Tomography: NCCT is now the imaging modality of choice in patients of acute renal
colic as it can visualise both peritoneal and retroperitoneal structures when diagnosis is in
doubt. Also if contrast is not needed but it cannot give information regarding renal function
needed for planning an intervention. However IV contrast if given can give this information.
HU can help predict stone type and hardness. Hard calcium oxalate monohydrate stones
frequently have HU >1000 whereas uric acid stones frequently have HU <500. Recently the
application of dual-energy CT (DECT) technology is demonstrating the potential to better
characterise stone type. In vitro studies using ratios of HU during DECT have been able to
distinguish among uric acid, calcium phosphate and calcium oxalate calculi. CT scans should
be used when the diagnosis is in doubt and should not be routinely utilised for diagnosis or
surveillance.
Intravenous Pyelography: IVP can simultaneously document nephrolithiasis and upper-tract
anatomy. It is rarely used today with the widespread availability of CT scan and ultrasound.
An inadequate bowel preparation, associated ileus and swallowed air, and lack of available
technicians may result in a less than ideal study when obtained during acute renal colic. A
delayed planned IVP may result in a superior study.
KUB films and Directed Ultrasonography: A KUB film and renal ultrasound may be as effective
as an IVP or CT scan in establishing a diagnosis. The USG should be directed towards
suspicious area on KUB. Edema and small calculi missed on an IVP can be appreciated with
such studies.

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 Retrograde Pyelography: Retrograde pyelography occasionally is required to delineate upper-
tract anatomy and localize small or radiolucent offending calculi.
MRI: Magnetic resonance imaging is a poor study to document urinary stone disease.
Nuclear Scintigraphy: Bisphosphonate markers can identify even small calculi that are difficult to
appreciate on a conventional KUB film. Nuclear scintigraphy cannot delineate upper-tract
anatomy in sufficient detail to help direct a therapeutic plan.

MANAGEMENT
Conservative
Spontaneous passage depends on stone size, shape, location and associated ureteral
edema. Ureteral calculi 4–5 mm in size have a 40–50% chance of spontaneous passage. In
contrast calculi >6 mm have a >15% chance of spontaneous passage. An alpha-blocker, non-
steroidal anti-inflammatory medications with or without low dose steroids is now becoming
standard care to optimise spontaneous ureteral stone passage. Dissolution agents like oral
alkalising agents can be used for stone dissolution. Cystine calculi can be dissolved with a
variety of thiols like d-penicillamine. Struvite stones however require acidification of urine.
Extracorporeal Shock Wave Lithotripsy
Extracorporeal SWL has revolutionised the treatment of urinary stones. Dornier a German
aircraft corporation rediscovered that shock waves originating from passing debris in the
atmosphere can crack something that is hard. Lithotripter requires an energy source to create
the shock wave, a coupling mechanism to transfer the energy from outside to inside the body
and either fluoroscopic or ultrasonic modes, or both to identify and position the calculi at a
focus of converging shock waves. ESWL device is a method of contact free destruction of
urinary stones. The stones are fragmented and passed via patients own urinary system.
ESWL is now considered first line treatment for renal calculus under 2cm. However pregnant
women and patients with large abdominal aortic aneurysms or uncorrectable bleeding
disorders should not be treated with ESWL. Also cystine calculi are resistant to breakage by
ESWL. Post ESWL patients should be encouraged to maintain an active ambulatory status to
facilitate stone passage. Gross hematuria should resolve during the first postoperative week.
Fluid intake should be encouraged. Abdominal pain may be related to shock waves. Although
shock waves are carefully directed on target tissue there is growing awareness that adjacent
tissue is subjected to trauma.
Ureteroscopic Extraction
Ureteroscopic stone extractions is highly efficacious for lower ureteral calculi.Stone free rates
approach 95–100% and are dependent on stone burden and location, length of time the stone
has been impacted, history of retro-peritoneal surgery and the experience of the operator. A
variety of lithotripter can be put through ureteroscope to fragment the stone.
Percutaneous Nephrolithotomy
Percutaneous removal of renal and proximal ureteral calculi is the treatment of choice for
large (>2.5 cm) calculi those resistant to SWL, select lower pole calyceal stones with a
narrow, long infundibulum this method can rapidly establish a stone-free status. Needle
puncture is directed by fluoroscopy, ultrasound or both, and is routinely placed from the
posterior axillary line into a posterior inferior calyx. Tract dilatation is done and stone is
extracted. Residual calculi can be retrieved with the aid of flexible endoscopes, additional
percutaneous puncture access, follow-up irrigations, SWL or additional percutaneous
sessions. Multiple percutaneous punctures are associated with a greater blood loss.
Open Surgeries
Open surgeries are rarely used now days. However impacted stones resistant to ESWL might
need removal by open technique.

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