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GASTROINTESTINAL AND ENDOSCOPY PACKAGES
Gastrointestinal and Endoscopy Packages
Package Procedures (Day Surgery)
Gastroscopy $290
Colonoscopy (LA w/o histology) - $650
Colonoscopy & Gastroscopy (LA w/o histology) $910
Gastroscopy
What is it?
A gastroscope is a bendy telescope about the diameter of a pen and about three feet long. This passes very easily down the throat and beyond. Strictly speaking a gastroscopy is just an examination of your stomach. But on the way, you are examined from the back of your mouth right down the oesophagus, the tube which runs inside your chest and connects the back of your mouth to your stomach. You may also be examined beyond your stomach into the upper part of the gut called the duodenum. Snippets of the lining of the stomach and other parts (biopsies) may be taken to help find out what is causing your problem. The Operation
First you will have your mouth and the back of your throat sprayed three or four times to make the lining numb. The spray tastes of orange and is a little sour. Then you have a fine, thin plastic tube put into a vein in your arm in case a sedative is needed. You will be turned to lie on your left side. You will be given a plastic tooth guard to bite on. Then the gastroscope is passed slowly down the back of your tongue. It tickles and makes fizzing noises. You will be asked to swallow once or twice to get the tube started on its journey down the back of your throat. You will be able to breathe normally, but you will find it difficult to talk because of the tube. You may feel your tummy swelling a little with wind as air is blown down the gastroscope to get a good view. You may even burp loudly. This is expected. The swelling soon passes off. Some people get a sickly feeling at one moment during the examination. This passes quickly. As the gastroscope is taken out at the end of the examination, it makes a noise in your mouth as it clears any secretions. You can always choose to have a general anaesthetic if you prefer. Any Alternatives
It is important to know what is going on inside your stomach and the other parts of your feeding (digestive) system. X-rays and scans are not the answer at this stage. Doing nothing may mean that something important may be missed. Before the operation
You will need to stop drinking and eating 12 hours before the examination. This will make sure your stomach is empty for the examination. Check you have a relative or friend who can come with you to the hospital and take you home. Bring all your tablets and medicines with you to the hospital. On the ward, you may be checked for past illnesses and may have special tests to make sure that you are well prepared and that you can have the procedure as safely as possible. . Many hospitals now run special preadmission clinics, where you visit for an hour or two, a few weeks or so before the operation for these checks. After - In Hospital
You may feel drowsy afterwards. You may in fact not remember the gastroscopy at all. You should not drink for one hour after the gastroscopy while your throat is numb. After two hours you can eat and drink normally. You can leave hospital after an hour or two provided someone goes with you. You may be given an appointment to visit the outpatient department for the result of the examination. Often your family doctor will handle the check up. Please ask the nurses about sick notes, certificates etc. After - At Home
You may feel tired for a day or so. The sedative will make you slow, clumsy and forgetful for about 24 hours. Do not make important decisions, drive a car, use machinery, or even boil a kettle during that time. Possible Complications
If you have this procedure under general anaesthetic, there is a very small risk of complications related to your heart and lungs. The tests that you will have before the procedure will make sure that you can have the it in the safest possible way and will bring the risk for such complications very close to zero. The examination is virtually free from complications. There may be some soreness of the throat for a day or so. Extremely rarely, especially if biopsies are taken, you can have some prolonged bleeding from the area of the biopsies or even a hole in your oesophagus or stomach that will require an operation to fix it. General Advice
The examination is very quick and easy. We hope these notes will help you through your operation. They are a general guide. They do not cover everything. Also, all hospitals and surgeons vary a little. If you have any queries or problems, please ask the doctors or nurses.
Colonoscopy
What is it?
Your symptoms point to your lower bowel being the cause of your condition. So far the tests have not been too helpful. The best way of finding out now is to do a colonoscopy. It has not been suggested before because it is a bit complicated and needs a stay in hospital. Some patients, such as those who have had a polyp in the bowel, need to have repeated colonoscopies to check that the bowel is healthy. The Operation
You will have a sedative injection or a short general anaesthetic. A colonoscopy means passing a flexible telescope (colonoscope) up the back passage into the lower bowel (colon) for a distance of about 5 feet (1.4 metres). Snippets of tissue can be taken, and polyps can be snared during the test. The bowel has to be cleaned out beforehand to give a clear view. You can plan to go home the evening of your colonoscopy, provided you have recovered from the examination. Any Alternatives
Leaving things as they are is really too risky for you. The tests so far are not an answer in themselves. A colonoscopy at this stage is better than an operation. Other forms of scanning are not as useful as a colonoscopy at this stage. Before the operation
Stop smoking and get your weight down if you are overweight. (See Healthy Living). If you know that you have problems with your blood pressure, your heart, or your lungs, ask your family doctor to check that these are under control. Check the hospital's advice about taking the pill or hormone replacement therapy (HRT). Check you have a relative or friend who can come with you to hospital and take you home. Bring all your tablets and medicines with you to hospital. On the ward, you may be checked for past illnesses and may have special tests, ready for the operation. You will be asked to fill in an operation consent form. Many hospitals now run special preadmission clinics, where you visit for an hour or two, a few weeks or so before the operation for these checks. You will be asked to go on a special diet 3 days before the colonoscopy. You will be given instructions about medicines to clear out the bowel before the operation. After - In Hospital
You may have slight tummy cramps as you get rid of air used during the examination. A general anaesthetic will make you slow, clumsy and forgetful for about 24 hours. Do not make important decisions, drive a car, use machinery, or even boil a kettle during that time. The discomfort of the operation can make it difficult to pass urine and empty the bladder. It is important that your bladder does not seize up completely. If you cannot get the urine flowing properly after 6 hours, contact the nurses or your doctor. You may be given an appointment to visit the Surgical Out Patient Department for a check up about one month or so after you leave hospital. Some hospitals leave check-ups to the General Practitioner. The nurses will advise about sick notes, certificates etc. You are likely to feel back to normal within 24 hours of the operation. You should not drive, use machinery or make important decisions for 24 hours after the anaesthetic. This is because the drugs used can slow the brain down for a time. You can restart driving within 24 hours of the anaesthetic. The test should not interfere with sexual relations. Possible Complications
Complications are rare and seldom serious. Making a split in the bowel wall is very rare. If you think that all is not well, please ask the nurses or doctors. There may be some bleeding for a day or two if a polyp has been snared. General Advice
The test is a minor procedure and is very safe. These notes should help you through your operation. They are a general guide. They do not cover everything. Also, all hospitals and surgeons vary a little. If you have any queries or problems, please ask the doctors or nurses. Gastrointestinal Carcinoid Tumors
General Information
The majority of carcinoid tumors are slow-growing tumors that can be treated and often cured, especially in early stages.The occurrence of metastasis from carcinoid tumors relates directly to the size of the primary tumor (lesions 1 cm or less rarely metastasize; lesions greater than 2 cm frequently metastasize). They are classified as neuroendocrine or amine precursor uptake and decarboxylation tumors. Rarely, they may be a part of the multiple endocrine neoplasia syndrome type 1. Carcinoid tumors may arise from various sites, most commonly the gastrointestinal tract and the lung. The appendix, small bowel, and rectum account for over 90% of surgical cases occurring in the gastrointestinal tract. Small bowel carcinoids may occur in multiple sites in the same patient. Symptoms may be chronic, suggesting partial obstruction or intussusception. Carcinoid tumors, except those originating in the rectum, produce a variety of endocrine substances, the most frequent of which are serotonin (5-hydroxytryptamine) and kallikrein (an activator of bradykinin release). The diagnosis of carcinoid syndrome (a syndrome associated with flushing, diarrhea, bronchoconstriction, cardiac valvular lesions, and telangiectasia) is aided by demonstrating elevated 24-hour urinary 5-hydroxyindoleacetic acid levels. This test is not useful in the diagnosis of carcinoids at a curable stage, except in some rare cases in which the tumor arises from a site outside of the gastrointestinal tract, such as the lung. Blood chromogranin A assay may also be a useful, though nonspecific, confirmatory test for carcinoid or neuroendocrine tumors. Primary carcinoids of the extrapelvic colon are uncommon, typically present with metastatic disease, and have a poor prognosis. Patients with carcinoid tumor are at increased risk for synchronous or metachronous second malignancies. The most common site for a second primary malignancy is the gastrointestinal tract.
The relatively rare carcinoid syndrome relates to the release of bioactive substances, but precise pharmacologic mechanisms are still unclear. Because of efficient hepatic metabolism of vasoactive amines, the carcinoid syndrome rarely occurs in the absence of liver metastases. Exceptions are circumstances where venous blood draining from tumors enters directly into the systemic circulation (for example, pulmonary and ovarian primaries, and pelvic or retroperitoneal involvement by metastatic or locally invasive small bowel carcinoids or extensive bone metastases).
Surgical resection is the standard curative modality. If the primary tumor is localized and resectable, 5-year survival rates are excellent (70%-90%). Even in patients with distant metastasis, the disease is usually very indolent, with median survivals of 2 years or more. When necessary, excellent palliation may be achieved by bypass surgery or resection of large hepatic metastases that may produce the carcinoid syndrome. Radiation therapy has a minor role in patients with regionally unresectable disease and may palliate the pain of bone metastasis. Patients with carcinoid syndrome can usually be effectively palliated by injections of somatostatin analogue 2 to 3 times a day. A long-acting somatostatin analogue that can be given as an injection once a month, with equivalent efficacy, is now available.
Patients with symptomatic metastatic carcinoid disease are appropriate candidates for clinical trials examining combination chemotherapy, since single-agent standard chemotherapy provides minimal palliation. However, chemotherapeutic drug combinations occasionally do offer long-lasting (in excess of 1 year) palliation. In patients with the carcinoid syndrome, palliation is sometimes obtained with pharmacologic agents that suppress production or block the action of vasoactive amines; of particular interest is a somatostatin analogue. Some patients benefit from the use of interferon alfa. Toxic effects associated with interferon treatment that frequently outweigh therapeutic gains can occur in some patients, but these effects are reversible once treatment has been discontinued and usually do not occur with smaller doses. Anecdotal reports of biologic activity indicate that some patients may respond to combined octreotide and interferon alfa treatment. Patients with asymptomatic metastases that cannot be resected for cure will often remain symptom-free for long periods of time.
Treatment Option Overview
The designations in PDQ that treatments are “standard” or “under clinical evaluation” are not to be used as a basis for reimbursement determinations.
Localized Gastrointestinal Carcinoid Tumors
Appendiceal carcinoids
For patients with appendiceal carcinoid tumors less than 1.5 cm in greatest diameter, appendectomy is adequate treatment with cure rates of essentially 100%. No follow-up management is required if the tumor is confined within the wall of the appendix. Tumors 1.5 to 2 cm in diameter can be treated by simple appendectomy or more aggressive surgical treatment. Tumors 2 cm or greater in diameter are less common, but must be considered malignant. Invasion of the mesoappendix does not alter prognosis, but invasion of the cecum mandates more extensive resection. When right hemicolectomy is performed, a lymphadenectomy, as performed for colon cancer, is appropriate.
Rectal carcinoids
For patients with rectal carcinoid tumors 1 cm or less in diameter, simple fulguration or local excision is adequate treatment. Cure rates of essentially 100% may be anticipated, and no follow-up management is required.
Tumors 2 cm or larger should be considered malignant and should be treated by an appropriate cancer operation, but sphincter-preserving procedures are preferred when possible. Otherwise, standard therapy includes abdominoperineal resection.
Tumors 1 to 2 cm in diameter can be treated either by local excision or by more radical resection. The decision should be based on actual size of the tumor, extent of invasion, and necessity for abdominal perineal resection versus a sphincter-preserving resection, and estimated operative risk. If local excision is elected, the patient should be carefully followed.
Small bowel carcinoids
For patients with small bowel carcinoid tumors less than 1 cm in diameter, conservative local resection is sufficient. For tumors greater than 1 cm in diameter, excision of a wedge of mesentery containing regional nodes is indicated.[3] Patients with tumors 1.5 to 2 cm or larger are at risk for recurrence; however, a standard surveillance program has not been established. A search for multiple primary lesions should be made in all patients with small bowel carcinoids.
Gastric, pancreatic, and colon carcinoids
Carcinoids of other sites in the gastrointestinal tract are rare. Optimal management of localized disease is aggressive surgical resection, although carcinoid tumors of the stomach and colon are typically less often localized than those in other gastrointestinal sites.
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