Liver metastases from colon or rectal cancer: moving from despair to hope

Returning readers would be well aware from my previous posts, how unique our liver is as an organ.

To summarise, 

The liver is the only organ that receives blood from two sources

1. the blood from the digestive tract, pancreas and associated organs enters the liver via the portal vein

2. the oxygenated blood from the general circulatory system enters the liver via the hepatic artery and its branches

Due to its responsibility of trapping, filtering and neutralising toxins, infective agents etc, most of the blood from the digestive tract and allied organs first passes through the liver before being circulated into the rest of the body.

Colon and rectal cancer is among the top 5 by way of incidence and cause of cancer related deaths in India.

In the last couple of decades, improvement in detection methods, availability of safe surgical techniques as well as introduction of better tolerated chemotherapy and targeted therapy have all helped improve survival in patients with cancer in general and colon and rectal cancer in particular.

Many patients with colon and rectal cancer can expect to survive more than 10 years after diagnosis making it a chronic stable disease like others.

The Achille's heel however is that when the cancer has metastasised ie spread to cells or tissues away from the original site, the chance of survival falls precipitously to a few weeks to a few months.

The American Joint Committee for Cancer (AJCC) even in its most recent iteration classifies presence of metastases as Stage IV, the last stage of colon or rectal cancer.

Since most of the blood from the colon or rectum is first carried to the liver via the portal vein, even cancer cells can travel by this route (they can also travel through the entire body by the hepatic artery route). The unique microscopic structure within the liver, traps these cells and they are believed to remain in the liver for at least sometime before they travel onward through the entire body. This property of the liver provides a putative window of opportunity for clinicians to treat the disease before it becomes generalised.

More than 70% patients with a diagnosis of colon or rectal cancer will develop metastases in the liver from time of diagnosis to death.

In about 30% of such patients, liver is the only organ to bear the metstatic burden.

In 10-15% patients, liver metastases are already present when the cancer is first detected. Such metastases are termed synchronous metastases.

In the rest, the metastases appear later and are called metachronous metastases.

As mentioned before, metastatic cells are considered to remain in the liver before spreading elsewhere.

There multiple options to treat metastases in the liver including 

liver surgery (hepatectomy)

liver transplantation

ablation techniques ( radiofrequency etc

Choosing the appropriate liver directed therapy depends on the site, size, number and location of the metastases as well as the patient profile.

Successful liver directed therapies have demonstrated a welcome trend towards  improved cancer free survival  and overall survival in recent studies with certain caveats

1. response to systemic therapy
2. completely resectable / no extrahepatic metastases
3. liver metastases completely resectable (R0)
4. adequate future liver remnant volume after resection

Liver directed therapies are complementary to systemic or targeted therapy and need to be timed and carried out in conjunction with a multidisciplinary team for optimal results.

Presence of metastases in both lobes of the liver present a vexing but not insurmountable challenge.

Combination of techniques concurrently or in a sequential or staged manner can completely rid the liver of all metastases with curative intent with meticulous planning and execution and for the rest liver transplantation does remain an option at least from the Scandinavian experience.

I personally have managed several patients who are surviving more than 5 years despite having been diagnosed with stage IV colon or rectal cancer and are still going strong.

So this is my shout-out to patients who have metastatic colon or rectal cancer, 

the age of despair is over, embrace the era of hope

How to make the liver strong....simple, Don't poison it!

I often get asked by people on social media, casual meetings or in my clinic what they can do to make their liver strong.

I have only one answer for them..."Don't poison your liver , it will remain strong"

Although my statement may seem anodyne or lacking in scientific basis, there is nothing further you need to do to keep your liver strong.

Almost everyone is born with normal liver structure and function. The liver is an amazing organ with hundreds of functions with more being recognised constantly.

The picture above captures only some of the functions of the liver as the list of functions is too exhaustive to enumerate in a simple manner.

Apart from being this amazing organ, the liver is also a remarkably resilient organ that possesses built in mechanisms to filter, breakdown or neutralise substances that could damage it.
Apart from this there is a significant redundancy or reserve built into the liver which allows it to keep functioning even when only one-third of it is structurally intact.

The liver also possesses the unique ability to repair and regenerate lifelong so that the damaged cells are replaced by new normal cells barring exceptional circumstances where there is sudden and massive damage to the entire liver.

From the above it must be clear to the readers that our liver is amazing, remarkably resilient and possesses almost inexhaustible capacity to repair damage. We should really be thankful to our liver for that.

So to reiterate, to keep our liver strong, we need not do much except to stop doing things that poison it beyond its capacity to repair and regenerate.

The liver is damaged by multitude of factors

drugs and toxins: including alcohol, certain medications, herbal products etc

excessive fat

infections caused by viruses including  hepatits and other viruses


So if we avoid all these factors to the best of our abilities, we are almost guaranteed to keep our liver healthy to last a life time.

There is no tonic or liver supplement that can keep your liver strong if you keep poisoning it by dietary excess, unnecessary toxic drugs, alcoholism or bad habits that keep on poisoning your liver, no matter what popular press or industry driven advertisements may proclaim.

Sometimes unavoidable medical situations require us to take medications or conditions like diabetes that lead to abnormal fatty acid metabolism may increase our risk of liver damage. Maintaining discipline, balanced diet and monitoring liver function under medical supervision can still effectively prevent liver dysfunction. Merely popping 'liver supplements' or unscientific 'liver cleanses' are unlikely to help despite the propaganda  surrounding them in social and popular media.

Once again dear readers

"if you want a strong liver....just don't poison it'

Alcohol : there is no safe limit

Alcohol or Ethanol intake is increasing in India and gaining social acceptance as we embrace western cultural influences to be part of the Global village. Of course this doesn't mean that alcohol intake is only an import from the west because alcohol abuse has long history even among traditional cultures, events and ceremonies. What western influence has done is to create an impression of alcohol being 'cool' thanks to subtle advertising, promotion of youth events and sports by alcohol manufacturers.

I recently read a newspaper article published in a local daily in Goa that published data from a nationwide household survey among those aged between 10-75 years conducted by teams from Union Misitry of Social Justice and Empowerment. This was called the 'Magnitude of substance abuse in India 2019'. It found that  the national average of alcohol intake prevalence was 14.9% among those between ages of 10-75 and that in males was significantly higher. My personal belief is the survey may have underestimated the data and if the age group was from 15-65 perhaps the figures would be much higher.

Gomantak Times 1st July 2019

Without beating around the bush, let us be clear about one thing....Alcohol is a cellular poison

A miniscule amount of ethanol is produced in our body by process of fermentation. So nearly all ethanol is what we consume.

More than 90% of ethanol consumed is dealt with by the liver. Minor amounts are dealt with by other organs and eliminated through breath or sweat. Ethanol metabolism in liver is a two step process as shown in accompanying diagram...and involves two main enzymes viz Alcohol dehydrogenase and Acetaldehyde dehydrogenase. While this process is very efficient it is neither limitless nor of equal efficiency in all. This is one of the main reasons why ill effects of alcohol are not uniform among all those who consume the same amount.

There are racial, genetic and other variations in how much a person can metabolise and that rate is unique for a person. If one consumes more or quicker than what one can metabolise, particularly in very large quantities over a short time ( binge drinking) or moderately large quantities persistently for many years the ill effects of alcohol are likely to be more severe.

The ill-effects of alcohol can be physical, mental or social. Suffice to say no aspect of a person's life is not at risk when alcohol abuse exists.

In this post I will confine myself to only the physical effects. Without exaggeration, no organ or tissue of the body is not at risk from ill effects of excess alcohol intake. It is a common misconception that alcohol is only a risk for the liver and the pancreas.

The accompanying graphic lists potential risks of alcohol intake but I must mention that a causal association between alcohol and all these disorders has not been firmly established. The statistical data supporting association however is fairly compelling to disregard.

Many people live under false assumptions that 'occasional drinking', 'social drinking'  or 'drinking beer' or ' drinking good quality alcoholic drinks', somehow provides them amnesty against its ill effects. Alcohol in any form or quantity has the potential to cause ill effects. However statistically the risk of liver disease is higher when more than 5-6 standard drinks are consumed by a man or more than 2-3 standard drinks are consumed by a woman in a week particularly if consumed for more than 5 years. I wish to warn the readers that this is only a statistical finding and only as far as the liver is concerned. It does not mean this is a recommended or safe amount because there is no reliable way to estimate an individuals capacity to metabolise alcohol safely.

There is some confusion in people's minds as to what a standard drink means.

1fl oz is about 30ml

The accompanying graphic sheds some light on internationally accepted definition of a standard drink.
As you can see all forms of alcohol can be considered a standard drink.

Alcohol not only can cause ill effects on its own but also amplify the ill effects of other substances as well as metabolic disorders like obesity and diabetes.

I often find patients lamenting their luck or negotiating that despite drinking much more, their friends have no problems. This is a facetious argument as every person is different and just because someone is not showing symptoms doesn't necessarily mean all is well.

So dear readers, don't drink
No amount of alcohol is 'all cool'

Surgical documentation: worth its weight in gold

Documenting surgical procedures performed can be very important and even cost and lifesaving.

Regrettably writing operation notes and documenting procedures is considered a menial task and delegated to the junior most member of the operative team in most places in India. As a result it leaves much to be desired.

I recently operated on a young woman who had as per her discharge undergone a Whipple's surgery ( an operation in which the gall bladder, lower part of the bile duct, head of the pancreas, first part of small intestine and sometimes part of stomach is surgically removed) more then a decade ago at a prominent cancer centre  in Bengaluru.

Whipple's operation

She presented with fever and jaundice and her MRI showed presence of gall bladder and stones in the bile duct with no apparent surgical connection between bile duct and intestines that one expects to be present after such a procedure. This flummoxed us as this picture is unexpected after a Whipple procedure.

Fortunately, the patient was able to procure the detailed records from a decade ago which had clearly documented that the procedure performed was not a Whipple procedure but an unconventional one where the gall bladder was retained and surgically connected to the intestine. This made the picture clear and we were successfully able to sort the problem by performing a second surgery to remove the gall bladder, remove the remaining bile duct and stones and establish a connection between the bile duct and intestine. This successfully relieved her jaundice and she made a full recovery.

I have no hesitation in admitting that it is the detailed record that allowed us to solve the puzzle which otherwise despite requiring multiple and costly scans could still have left us in some doubt before the surgery. The documentation provided us a clear roadmap regarding what to expect and formulate a plan to deal with it beforehand.

As a rule I make it a point to write operative notes on my own. Being the lead surgeon,  I have the experience and insight to document all the necessary details that could be needed later. Writing the notes immediately ensures that details are fresh in memory and not forgotten. 

I often find  myself lamenting this lack of attention to detail when I see patients who have previously undergone surgery with only sketchy or woefully inadequate details available regarding the operative findings and nature of the surgery. These omissions can lead to escalated costs and make reoperative surgery difficult like groping in the dark.

This is a shout out to my surgical colleagues to pay attention to documenting clearly all surgical details ...it could save your patient a lot of angst, cost and even their lives.

Doctors day: acts not words

July 1 is commemorated in India as 'Doctor's day' celebrating Dr BC Roy, a physician politician who was the second CM of West Bengal.

July 1 is both his birth (1882) and death (1962) anniversary.

An award named after him is a much coveted award among doctors in India.

Like many of my professional colleagues, my mailbox and social media is peppered with messages wishing me a 'Happy Doctor's day'. Most of these messages are from patients or their relatives and some from my staff and representatives of pharmaceutical companies.

I sincerely thank them all.

They say feeling gratitude and not expressing it is like wrapping a gift but not delivering it.

However in the light of the current situation of doctor-patient relationship in India, one cannot but feel cynical and reflect.

Are doctors owed any gratitude for doing their professional duty particularly when they charge a fee for their services?

I feel nobody is entitled to gratitude or praise for doing their professional duty whether they do it for a fee or pro bono. Doctors are human beings and trained professionals and therefore susceptible to the frailties and fallibility of both. Medical science like most sciences is evolving and not perfect and ascribing nobility or demigod status to a professional is  inappropriate.

Every dog has his day

This is a pretty well known proverb. So having a Doctor's day without having a healthy relationship with the profession is only a meaningless candyfloss Hallmark moment.

Both the medical profession and society need each other and must find ways to reduce the trust deficit that has got created, mainly in my opinion due to exaggerated reports of medical apathy or lack of sensitivity in irresponsible media. Such negative campaigns have created a confirmation bias that leads people to suspect the intentions of their doctor at every step. If you cannot trust your doctor to act in your best interest, continuing to be his patient is a meaningless exercise.

So a real doctor's day wish to your doctor would be to treat your doctor as a human being who is a trained professional, nothing more and nothing less. He needs your trust not your gratitude and praise for doing his duty. And for some reason if you don't trust him, please move on to some other you trust rather than continue the relationship is an atmosphere of cynicism and mistrust that helps nobody.

Your actions speak so loudly that I cannot hear your words

Abdominal pain: a common symptom but can be difficult to diagnose

Some causes of abdominal pain by location

Abdominal pain is a common symptom for which many patients approach their physician.

The pain is described as stabbing, crampy, aching or burning and the intensity can vary from slight discomfort to agonizing pain.

Although it seems simple to diagnose the cause, abdominal pain in many cases can be very difficult and elusive. In fact in about 1 in 10 cases, no cause may be found.

Why is this so?

The abdomen is a part of the body that holds within it multiple organ systems viz the gastrointestinal system, the urinary system and internal genital organs (in the female). The great vessels of the body, the aorta and the inferior veins cava also pass through the abdomen. Apart from this there is a large potential space between the internal lining of the abdominal cavity (the peritoneum) and the muscles of the back and vertebral column. This space called the retro peritoneum contains multiple tissues like fat, nerve tissue and lymphatic tissue. Any of these may be the cause of abdominal pain and looking for a source can be like looking for a needle in the proverbial haystack.

To further befuddle the diagnostician, pain in abdomen may not be related to an abdominal source at all but may be the result of a problem in the organs of the chest including the ribs, lungs and their lining (pleura) or the heart and its covering sac ( pericardium).

As Pandora's box in Greek mythology
https://en.m.wikipedia.org/wiki/Pandora's_box had all the sins of the world trapped in it, the abdomen can have many problems trapped in it. Hence the abdomen is often called the 'Pandora's box of the body'.

To reach a diagnosis it is important to get a detailed clinical history, perform meticulous clinical examination and appropriate laboratory and radiological tests.

Abdominal pain particularly if  acutely severe or chronic or longstanding can be challenging and should warrant attention by a trained gastroenterologist and should not be ignored.

Welcome

Welcome to my blog

Trawling the world wide web for credible health information is on the rise.

However sifting credible information from fake news, unverifiable anecdotes and misleading propaganda is often laborious and difficult.

Information asymmetry between what the person knows about his medical problems and what he or she should know is a major obstacle in achieving optimal treatment goals. Reducing this asymmetry is to the advantage of both the healthcare provider as well as the patient or customer as it leads to a more satisfying experience out of the interaction.

This blog is an effort on my part to dissipate credible information in a simple manner

drawing on my reading, training and clinical experience of more than 15 years regarding disorders of the gastrointestinal tract, liver, biliary system and pancreas and take a step towards reducing the information asymmetry to allow people to hopefully get more insight into the conditions they are affected by and help make a more informed choice regarding how to deal with them.