- Diseases of the stomach, duodenum, ampulla, bowel and mesentery, spleen, adrenal glands and retroperitoneum
- Stomach disease
- Diseases of the duodenum
- Diseases of the ampulla of Vater
- Carcinoid tumors of the bowel (usually involve the small bowel and the mesentery and the liver)
- Mesenteric tumors
- Diseases of the spleen
- Adrenal tumors
- Retroperitoneal tumors
Diseases of the stomach, duodenum, ampulla, bowel and mesentery, spleen, adrenal glands and retroperitoneum
Stomach diseaseStomach tumors
Stomach cancer
Stomach cancer is an aggressive cancer. It usually presents as abdominal pain or bleeding, which leads to endoscopy finding an ulcer, which is biopsied and the biopsy results confirms stomach cancer. Further workup is done to evaluate for evidence of spread (metastases). If metastases are found, they can be in the liver or in the lymph nodes around the stomach or in the lung. If there is spread, there is no role for surgery. However, if there is no evidence of metastatic disease, surgery does have a major role. Usually chemotherapy is done prior to surgery. At surgery, depending on the location of the cancer, a complete removal of the stomach or removal of ¾ of the stomach is done and then a new connection with the small bowel is performed. After surgery, depending on the pathology, additional chemotherapy and sometimes radiation therapy is necessary.GIST
GIST stands for Gastro-Intestinal Stromal Tumor. This is a tumor which arises from the pace-maker cells of the gastrointestinal tract and can be found in the stomach as well as other parts of the intestine. It varies in aggressiveness. It does not spread to lymph nodes but can spread to the liver and lung. It is preferred to be treated with medication Imatinib (Gleevec) before surgery. The use of the medication allows for the tumor to shrink in size. Then surgery is performed. Unlike surgery for stomach cancer, surgery for GIST does not require a large part of the stomach to be removed and usually a wedge of the stomach wall, containing the tumor, can be safely cut around with a narrow margin. In that sense, depending on the individual circumstances, it is possible to preserve most of the stomach, without the need for a new connection with small bowel, which again is different than surgery for stomach cancer.Benign strictures of the pylorus
Peptic ulcer disease is the disease that causes ulcers in the stomach and duodenum, which are not cancerous but may result in scarring and narrowing of the outlet of the stomach, which is called pylorus. That may cause blockage of the path of the food leaving the stomach with inability to eat. First an endoscopy is needed to confirm that and to obtain a biopsy to make sure a cancer is not missed. Sometimes cancer cannot be ruled out. A surgery may be indicated, which includes removal of the narrow 1/3 of the stomach (antrectomy) and reconnection with the small bowel (gastrojejunostomy).Procedures on the stomach
Total gastrectomy with D2 dissection lymphadenectomy
This is the operation which removes the entire stomach and then makes a new connection between the esophagus and the small bowel (esophagojejunostomy). An important part of the operation is to remove all the lymph nodes to which stomach cancer tends to spread (lymphadenectomy). These lymph nodes include not only the lymph nodes around the stomach (D1 dissection), but also lymph nodes around the major vessels in the upper abdomen (D2 dissection). D2 dissection is superior from cancer treatment perspective compared to D1 in experienced hands. Dr. Donchev has the expertise to perform D2 dissection and is offering it to his patients. Risks of the operation include major bleeding as dissection around major vessels is done as well as leak from the connection between the esophagus and the bowel. The severity of the leak may range from fluid detectable in the drains to a life threatening condition. Because eating by mouth is not possible until the connection heals, which may be long if there is a leak, a feeding tube is also placed. As there is no stomach left, the operation leads to significant weight loss.Subtotal gastrectomy with D2 dissection lymphadenectomy
This is the operation which removes ¾ of the stomach and leaves a small pouch, which is connected to the small bowel. Similar to total gastrectomy, an important part of the operation is to remove all the lymph nodes to which stomach cancer tends to spread (lymphadenectomy). These lymph nodes include not only the lymph nodes around the stomach (D1 dissection), but also lymph nodes around the major vessels in the upper abdomen (D2 dissection). D2 dissection is superior from cancer treatment perspective compared to D1 in experienced hands. Dr. Donchev has the expertise to perform D2 dissection and is offering it to his patients. Risks of the operation include major bleeding as dissection around major vessels is done as well as leak from the connection between the stomach and the bowel. The severity of the leak may range from fluid detectable in the drains to a life threatening condition. Because eating by mouth is not possible until the connection heals, which may be long if there is a leak, a feeding tube is also placed. As there is a very small stomach pouch left, the operation leads to significant weight loss.Partial gastrectomy
Partial gastrectomy is performed for benign disease. It removes about half of the stomach. The stomach is then connected to the small bowel (gastrojejunostomy). It also has a risk of leak, but it is smaller than when removing larger portions of the stomach.Antrectomy
Antrectomy is a variant of partial gastrectomy and removes about 1/3 of the stomach which is called antrum. It is used as a surgical way of treatment of ulcer disease, when medication treatment has failed. The stomach is then connected to the small bowel (gastrojejunostomy). It also has a risk of leak, but it is smaller than when removing larger portions of the stomach.Gastrojejunostomy
Gastrojejunostomy is a surgical connection that is made between the stomach (gastro-) and small bowel (jejunum). It can be done in two different ways, loop gastrojejunostomy and Roux-en-Y gastrojejunostomy.Loop gastrojejunostomy
Loop gastrojejunostomy is when a loop of bowel is brought to the stomach and a new connection is made by suturing or stapling the two together.Roux-en-Y gastrojejunostomy
Roux-en-Y gastrojejunostomy is when a segment of bowel, looking like a candy-cane (and not like a loop) is brought to the stomach and a new connection is made by suturing or stapling the two together. The name comes after the French-speaking Swiss surgeon from the end of the 19th century and the beginning of the 20th century who first invented that method. His name is Cesar Roux. Y-comes from the fact that the candy-cane is connected to the rest of the small bowel in a way that looks like the letter Y.Wedge resection of the stomach
Wedge resection of the stomach is done for GIST tumors. Instead of removing a third, or a half or three-quarters or the entire stomach (as it is done for stomach cancer), a wedge of stomach wall, containing the GIST tumor is done with narrow margin and that is adequate for the treatment of this particular type of tumor but not for cancer.Pyloroplasty
Pyloroplasty is a procedure where the narrow muscular ring at the outlet of the stomach, called pylorus, is opened lengthwise and is closed sideways. That is done when the pylorus has scarred down from chronic inflammation due to ulcer (but not cancer).Diseases of the duodenum
The duodenum is the part of the intestine into which the stomach transitions. It has a very special anatomical location, because it is very close to many other important structures. The duodenum “hugs” the pancreas. The duodenum and pancreas have common blood supply. The bile duct and pancreatic duct open into the duodenum. The biggest abdominal vessels are travelling on top, behind or in front of the duodenum. The duodenum is where many digestive juices are flowing into (stomach juice, bile, pancreatic juice, duodenal’s own juice). Because of this central location, surgical operations of the duodenum are challenging. Operations on the duodenum have a higher risk of leaking compared to other parts of the intestine.Duodenal tumors
Duodenal cancer
Duodenal cancer is an aggressive disease, which however has better prognosis than pancreatic cancer. It tends to spread to the lymph nodes around the major vessels in the upper abdomen and also to the liver. The difference with pancreatic cancer is that the patient would be considered a surgical candidate even if there are metastases to the liver, provided that they can be removed, as opposed to pancreatic cancer, in which case if there are metastases to the liver, that is a clear indication not to do the surgery. If there is spread to the liver and lymph nodes, chemotherapy is also required. Depending on the individual circumstances it can be done before or after surgery. The treatment for duodenal cancer is a Whipple procedure.Duodenal GIST
Duodenal GIST is the same type of tumor (Gastro-Intestinal Stromal Tumor), described previously in the stomach section, but when it is located in the duodenum. Similarly to the stomach, duodenal GIST does not spread to the lymph nodes but can spread to the liver. Similarly to the stomach, duodenal GIST needs only a narrow margin of resection. However, the unique anatomy of the duodenum and its relations to the pancreas and bile duct are dictating the surgical operation which is needed. If the GIST is opposite side to the pancreas and bile duct, it can be removed by cutting a narrow margin from the duodenal wall and connecting with the small bowel (anastomosis, duodeno-jejunostomy). If the GIST is on the pancreas/bile duct side, most commonly a Whipple procedure is required.Neuroendocrine tumors of the duodenum
They are similar to the neuroendocrine tumors of the pancreas but form in the wall of the duodenum on its pancreatic side. They may be able to be removed by a limited resection of a disc of duodenal wall when they are really small. When they are bigger, a Whipple procedure is required.Duodenal lymphoma
Duodenal-type follicular lymphoma is a malignancy of the immune cells within the wall of the duodenum. It is not normally treated by surgery. However, it may develop complications of blockage, perforation or bleeding. Surgical treatment of complications is needed.Duodenal ulcer
Duodenal ulcer most commonly is successfully treated with medications. Surgery is reserved for complications. Complications are bleeding, perforation or narrowing of the duodenum due to scarring down of the ulcer.Procedures on the duodenum
Segmental resection of the duodenum and wedge resection of the duodenum
Segmental resection of the duodenum is removing of a segment of the duodenum. Wedge resection of the duodenum is removing of a wedge of the wall of the duodenum opposite to the pancreatic side. These two procedures may be performed, depending on the local circumstances, in cases of duodenal GIST. If the GIST is on the pancreatic side of the duodenum, then a segmental or wedge resection is not possible.Whipple procedure
Please refer to the section on pancreas for details on Whipple procedure. In cases of duodenal disease, Whipple procedure is performed for duodenal cancer or neuroendocrine tumor or when a duodenal GIST involves the pancreatic side of the duodenal wall.Antrectomy with gastrojejunostomy
Antrectomy is removal of the stomach antrum, which is the distal 1/3 of the stomach. Along with it a various length of the first part of the duodenum is removed. It is done for peptic ulcer not responsive to medical treatment and for narrowing of the pylorus or the first part of the duodenum from scarring of the ulcer.Diseases of the ampulla of Vater
The ampulla of Vater (named after Abraham Vater, a German anatomist) is the structure where the bile duct and the pancreatic duct join together and then open into the duodenum.Ampullary cancer
Ampullary cancer is a cancer which involves the ampulla of Vater. It is one of the forms of cancer in that area which are collectively named periampullary cancers. They include ampullary cancer, duodenal cancer, pancreatic head cancer, distal bile duct cancer.Neuroendocrine tumors of the ampulla of Vater
Neuroendocrine tumors of the ampulla are similar to neuroendocrine tumors of the duodenum, but they specifically involve the ampulla. When they are small, they can be removed by opening the duodenum and cutting them out (transduodenal ampullectoy). When they are bigger, a Whipple procedure is required.Ampullary adenoma
Ampullary adenoma is a benign counterpart of the ampullary cancer. When it is small it can be removed endoscopically (endoscopic ampullectomy). When it is bigger but not too big, it can be removed by opening the duodenum and cutting it out (transduodenal ampullectomy). When it is really big, a Whipple procedure is required.Procedures on the ampulla of Vater
Whipple procedure
For details, please see the pancreas section of this website.Transduodenal ampullectomy
Transduodenal ampullectomy is a procedure, where the second part of the duodenum is opened and through it, its backwall on pancreas side is visualized. Then the ampulla of Vater is pulled up and cut around until it is removed completely. Then a complex repair, suturing the bile duct and the pancreatic duct from inside to the lining of the duodenum is performed. It is done for ampullary adenoma and ampullary neuroendocrine tumors, when they are small enough. If they are bigger, then a Whipple procedure is required.Carcinoid tumors of the bowel (usually involve the small bowel and the mesentery and the liver)
Carcinoid tumors are neuroendocrine tumors of the bowel. Most commonly they are located in the end of the small bowel but may be seen in any location of the small or large bowel. They tend to spread to the lymph nodes of the bowel mesentery and also to the liver. Sometimes, the primary tumor in the bowel is small while the metastases to the lymph nodes may be large, causing a mesenteric mass. The diagnosis is made by a combination of imaging (mesenteric mass on CT), laboratory tests (elevated Chromograning A and HIAA), Gallium-DOTATETE scan and sometimes endoscopy and biopsy. Surgery and hormonal therapy with octreotide are the main stay of treatment.Procedures for neuroendocrine tumors of small bowel
Small bowel resection with resection of mesenteric mass with or without liver resection
When there is a carcinoid tumor, the involved segment of bowel is removed along with the mass in the mesentery, which is usually a large bulky metastatic spread to mesenteric lymph nodes. If there is spread to the liver, the liver tumors may be removed on the same operation or as a separate operation.Mesenteric tumors
Mesenteric tumors are rare tumors in the mesentery. The mesentery is a structure that looks like a fan and extends from the back wall of the peritoneal cavity to the bowel. It contains the vessels of the small bowel and fat. Because all the blood vessels for the entire small bowel run through the mesentery, if a mesenteric tumor forms centrally, where the main artery and vein are, it becomes very difficult and risky to remove the tumor as injury of the main artery or vein of the bowel may result in dying of the entire small bowel which is not survivable. Because of that operations for mesenteric tumors may be challenging.Procedures for mesenteric tumors
Resection of mesenteric tumor with segmental bowel resection or en bloc multi-visceral resection
Depending on the location of the mesenteric tumor, certain blood vessels supplying the bowel will need to be sacrificed along with the segment of the bowel, which is supplied by these blood vessels. Sometimes, in order to remove the mesenteric tumor, several different organs need to be removed at the same time. These may be a very complex and difficult procedures.Diseases of the spleen
The spleen is located at the tail of the pancreas. It is a very vascular organ which easily bleeds massively when injured during an operation. Its function is to destroy old blood cells (red, white, platelets) and also is a part of the immune system. As part of the immune system it is responsible for protection against certain germs, more specifically against the germs causing pneumonia, meningitis and epiglottitis (swelling of the throat). Because of that, when the spleen is removed surgically, vaccination against these three organisms is necessary in order to decrease the risk of overwhelming infection.Lymphoma
Lymphoma is a malignancy originating from the immune cells. As the spleen is part of the immune system, lymphomas localized to the spleen may occur. In such cases, removal of the spleen (splenectomy) may be recommended. Sometimes, removal of the spleen may be done in order to make a diagnosis of the lymphoma, which may be suspected but not confirmed on pathology. When the lymphoma is only in the spleen, removal of the spleen may cure the disease. The patient may still need chemotherapy after that though.Idiopathic thrombocytopenic purpura (ITP)
Idiopathic thrombocytopenic purpura is an auto-immune disease, in which the body produces auto-antibodies, which tag the otherwise normal platelets for destruction in the spleen and that results in dangerously low platelet counts which may result in spontaneous bleeding. If non-operative treatment fails, removal of the spleen (splenectomy) may be necessary.Sinistral portal hypertension
The blood vessels of the spleen are closely related to the blood vessels of the stomach and pancreas. Sometimes diseases of the pancreas result in clotting of the vein of the spleen (splenic vein), which drains blood from the spleen into the liver. When that happens, the blood outflow from the spleen is re-directed through short veins connecting the spleen and the stomach. That can result it bleeding in the stomach which may be massive. The treatment includes removal of the spleen. However, if there is a pancreas disease identified, which causes the clotting of the splenic vein, which created the problem on the first place, this needs to be addressed as well. If that is a tumor of the pancreas, it may need to be removed as well.Procedures on the spleen
Splenectomy (open, robotic, laparoscopic)
Removal of the spleen (splenectomy) can be done open or minimally invasive (robotic, laparoscopic). Open splenectomy is usually done in emergent situations, when the spleen is ruptured and there is active ongoing bleeding in the abdomen. When the condition, requiring splenectomy, is not emergent, then the spleen can be removed minimally invasively. Dr. Donchev offers robotic splenectomy. If there is a reason not to use the robot, then a conventional laparoscopic removal of the spleen is used as an alternative.Adrenal tumors
The adrenal glands are organs which look like caps, sitting on top of each kidney. So, they are two – left and right. They produce important hormones, regulating the levels of sodium and potassium in the blood, the production of glucose in the body and response to stress and also the adrenal glands are the site where adrenaline is produced, which is responsible for regulation of blood pressure and also stress response. The adrenal glands can develop tumors, some of which are benign and inconsequential and can safely be observed. In other cases, these tumors are producing excess hormones or may start to grow rapidly and then are concerning for cancer. Yet in other cases, the cancer may be evident. In all of these cases, the adrenal gland needs to be removed.Adrenal adenoma
Adrenal adenoma is a benign tumor of the adrenal glands. It is usually discovered incidentally on CT performed for another reason. Most commonly is small and has a typical appearance. If that is the case, the next step is to perform a panel of biochemical tests to make sure that it is not producing dangerously high levels of hormones. If there are high levels of hormones, even if the adenoma is small, it needs to be removed. Most of the time, the adenoma is not producing hormones. Then, it is monitored with repeat CT scans over a period of time. If it remains stable, no further following is necessary. If it demonstrates growth, depending on the individual circumstances, it may need to be removed.Adrenal carcinoma
Adrenal carcinoma is an aggressive tumor that requires removal of the adrenal gland. Sometimes it grows to a very big size and occasionally removal of additional adjacent organs is required.Pheochromocytoma
Pheochromocytoma is a tumor that originates from the center of the adrenal gland and is producing adrenaline (epinephrine) or another like hormone, called norepinephrine. Because of the high biological activity of epinephrine and norepinephrine, they may be released in massive doses during surgery. Because of that, prior to surgery, a special process is followed to block the effects of epinephrine and norepinephrine on the sensitive organs, most specifically the heart and the blood vessels. If that protocol is not followed a dangerous arrhythmia and very high blood pressure may occur, which may result in death of the patient during anesthesia.Isolated adrenal metastases from other cancers
The adrenal glands may be a site of metastatic spread of other cancers. In some cases, removal of the affected adrenal gland may be performed if that is the only site of spread and the primary cancer is removed as well.Procedures on the adrenal glands
Adrenalectomy (left or right) (open, robotic)
The operation to remove the adrenal gland is called adrenalectomy. Depending on the affected gland, it may be a right adrenalectomy or a left adrenalectomy. The anatomical relations of the two glands are different. While they both are located on top of each kidney, the other surrounding organs are different. The right adrenal gland is under the right half of the liver and is abutting the largest vein in the body, called IVC. The left adrenal gland is behind the left part of the colon, the tail and body of the pancreas and the spleen. In order to get to the adrenal gland of interest, the surrounding organs need to be reflected away. If the tumor of the adrenal gland is small, the operation can be done robotically or laparoscopically. The robotic approach is preferred. If the tumor is larger, an open operation is needed.Retroperitoneal tumors
Retroperitoneal tumors arise from the soft tissue that lines the back wall of the abdominal wall, behind all other organs. They may grow to very large sizes and may be difficult to remove due to involvement of multiple important organs and blood vessels. There are usually no good options for chemotherapy or radiation and surgery is the mainstay of treatment.Procedures for retroperitoneal tumors
Complex retroperitoneal resections with or without en bloc multi-visceral resections
Depending on the location of the tumor and the degree of involvement of the surrounding organs, a very complex operation which may need to remove several organs altogether at the same time (en bloc), while trying to preserve important blood vessels, may need to be done and then complex reconstruction of the divided organs is required.