Gastrointestinal Oncological Surgery

The gastrointestinal oncology surgery team at the University Clinic for Visceral, Transplant, and Thoracic Surgery in Innsbruck deals with the diagnosis and treatment of both benign diseases of the gastrointestinal tract (chronic inflammatory bowel disease, diverticulosis/diverticulitis) and malignant tumors of the gastrointestinal tract (stomach, small intestine, colon, and rectum), the peritoneum, and sarcomas (malignant soft tissue tumors) of the abdominal cavity.

At the University Clinic for Visceral, Transplant, and Thoracic Surgery in Innsbruck, we offer treatments for these diseases, among others:

• Colorectal carcinoma
  • Colon carcinoma
  • Rectal carcinoma
• Gastric carcinoma
• Gastrointestinal stromal tumor (GIST)
• Abdominal sarcomas (intra- and retroperitoneal)
• Peritoneal malignancies (malignant tumors of the peritoneum)/HIPEC
• Small bowel tumors
• Hereditary gastrointestinal tumor syndromes
• Chronic inflammatory bowel diseases (IBD)
  • Ulcerative colitis
  • Crohn’s disease
• Diverticulosis/Diverticulitis

Colorectal carcinoma

Colorectal cancer is the third most common cancer in Austria for both sexes, with an incidence of 4,467 new cases per year (as of 2022, Statistics Austria). For early detection, non-invasive tests for blood in the stool are offered, and a complete colonoscopy is recommended from the age of 45, during which adenomas—the precursor to carcinoma—can be removed if necessary.

Colorectal carcinoma

• Symptoms: Blood in/on the stool, changes in bowel habits, pain, intestinal obstruction, but also nonspecific symptoms such as loss of energy, unintentional weight loss, and symptoms of anemia.
• Diagnostics: digital rectal examination, colonoscopy with biopsy including immunohistochemistry (microsatellite stability), computed tomography for staging, tumor markers in the laboratory.
• Therapy: Provided there are no distant metastases, colon cancer is treated by primary surgical removal of the tumor with an appropriate safety margin to healthy tissue, including the locoregional lymphatic drainage area (total mesocolic excision). For patients with advanced tumors that have spread, e.g., to the liver or lungs, an individual treatment plan is drawn up after consultation with the interdisciplinary tumor board. The need for supplementary (adjuvant) chemotherapy after surgery is also evaluated by the interdisciplinary tumor board
  

Rectal carcinoma

• Diagnosis: In addition to the diagnosis of colon cancer, an MRI scan of the pelvis is mandatory and crucial for determining the exact location of the tumor (upper/middle/lower third of the rectum) and its spread.
• Treatment:
  • If located in the upper third of the rectum, the treatment is the same as for colon cancer.
  • Very small tumors in the middle and lower third of the rectum can be removed locally or by resection (partial/total mesorectal excision, PME/TME) under certain, precisely defined conditions.
  • For all other tumors located in the middle and lower third of the rectum, a multimodal therapy concept with preoperative radiation and chemotherapy is currently used.  The aim of this therapy is to reduce the (local) recurrence rate and to preserve the organ, i.e., to avoid a permanent artificial bowel outlet. A standard treatment concept can no longer be defined at these stages; each case is discussed in an interdisciplinary tumor board.

Gastric carcinoma

• Symptoms: Since stomach cancer rarely shows early or warning symptoms, it is usually discovered by chance during a gastroscopy. In advanced tumors, swallowing difficulties, pain, or vomiting may occur, as well as nonspecific general symptoms such as fatigue and weight loss.
• Diagnosis: Gastroscopy with biopsy, computed tomography to diagnose the extent of the disease, endosonography for localized disease.
• Therapy:
  • The decision on the recommended treatment regimen depends on the size and extent of the gastric carcinoma and is made at the weekly interdisciplinary gastrointestinal tumor conference. Except for very early tumor stages, where surgical or endoscopic resection alone is sufficient, the treatment of gastric cancer today consists of preoperative chemotherapy, followed by surgical resection of the tumor and lymphatic drainage pathways (D2 lymphadenectomy) and subsequent postoperative chemotherapy (known as perioperative chemotherapy).
  • If possible from an oncological point of view – the internationally valid radicality criteria for surgery in gastric cancer are strictly adhered to at our clinic – we aim to preserve the remaining stomach, as the quality of life is significantly better compared to total removal of the stomach (gastrectomy).
• We pay particular attention to nutritional counseling after the operation, where trained dieticians are on hand to provide patients with advice and support.

Gastrointestinal stromal tumor (GIST)

• Gastrointestinal stromal tumors (GISTs) are rare tumors of the gastrointestinal tract, with an incidence of approximately 10 – 15 per 1,000,000 inhabitants.
• GISTs are distributed throughout the entire gastrointestinal tract (esophagus 5 %, stomach 40 % – 70 %, duodenum 6 %, small intestine 20 % – 35 %, and colon and rectum 5 % – 15 %).
• Symptoms: Due to the varying locations, symptoms can also be very different or nonspecific. In up to 30% of patients, GISTs are diagnosed incidentally during endoscopic examinations or operations for other indications. Approximately 10% of cases are diagnosed as emergencies, for example during emergency surgery for intestinal obstruction or perforation, or due to bleeding in the digestive tract or abdominal cavity.
• Diagnosis: In addition to endoscopy and endosonography, computed tomography is used to diagnose the spread of the tumor, and biopsy with molecular genetic testing is used to determine the KIT or PDGFRA mutation status in GISTs for which drug therapy is indicated.
• Therapy: Primary resection with a safety margin is the treatment of choice for resectable GIST tumors. If complete tumor resection does not appear possible, neoadjuvant, i.e., preoperative therapy with imatinib is used to reduce the size of the tumor.

Abdominal (intra- und retroperitoneal) sarcomas

• Soft tissue sarcomas are a heterogeneous group of malignant tumors that account for approximately 1 % of all malignant tumors.
• Symptoms: Symptoms typically occur late, when the tumor has grown significantly in size, causing displacement and compression.
• Diagnosis: Computed tomography and/or magnetic resonance imaging. After imaging diagnostics, a biopsy may be performed to confirm the exact histological diagnosis.
• Therapy: Interdisciplinary therapy planning in the tumor board is essential for the success of treatment, which focuses on radical surgery. This often requires extensive surgery, often involving the removal of several adjacent organs (multivisceral resections). However, the long-term success of such an operation can only be achieved in combination with other therapies (radiotherapy, chemotherapy).

Peritoneal malignancies (malignant tumors of the peritoneum)//HIPEC

• Malignant tumors of the peritoneum are divided into tumors that originate primarily in the peritoneum and tumors that secondarily affect the peritoneum as metastases (peritoneal carcinomatosis). Primary tumors include, for example, peritoneal mesothelioma and pseudomyxoma peritonei. Secondary tumors of the appendix (often referred to as the “blind intestine”) relatively frequently spread to the peritoneum.
• Symptoms: Uncharacteristic general symptoms such as fatigue, loss of appetite, weight loss, and unexplained fever (B symptoms). In later stages, abdominal girth increases due to ascites formation and large tumor nodules.
• Diagnosis: Gastroscopy and colonoscopy, computed tomography, staging laparoscopy to assess tumor extent, laparoscopy to obtain histology prior to initiating therapy in cases of inoperable tumors
• Therapy: The only curative treatment option for these aggressive tumors is a combination of surgical removal of all visible tumor nodes (cytoreductive surgery, CRS) and intraperitoneal chemotherapy during surgery (hyperthermic intraperitoneal chemotherapy, HIPEC). The operation is often accompanied by multivisceral resection (removal of several organs) and removal of parts or all of the peritoneum (peritonectomy).
• As the largest peritoneal carcinomatosis center in western Austria, we have been performing this highly specialized treatment since 2006.

Small intestine tumors

• Compared to colon or stomach cancer, small intestine tumors are a rare type of tumor
• Depending on which cells are the starting point of the malignant degeneration in the small intestine, these are completely different types of cancer with different treatment strategies and, above all, different prognoses (carcinomas, neuroendocrine tumors, gastrointestinal stromal tumors, lymphomas, …).
• Symptoms: The main symptoms of small intestine tumors are bleeding or intestinal obstruction. Small intestine tumors are often only discovered by chance during emergency surgery.
• Diagnostics: Computed tomography and/or magnetic resonance imaging
• Therapy: Due to the symptoms at diagnosis (bleeding/intestinal obstruction), surgical removal of the tumor is almost always necessary, regardless of the type of cancer. Whether subsequent chemotherapy or other drug therapy is necessary is decided in an interdisciplinary gastrointestinal tumor conference.

Familial (hereditary) tumor diseases of the gastrointestinal tract

• Changes in genetic material (“mutations”) play a decisive role in the development of tumors.
• If stomach or colon cancer occurs frequently in a family among blood relatives or at an unusually early age, it makes sense to perform certain genetic tests on blood samples in order to assess the risk of developing a tumor disease among family members.
• Similarly, after tumor surgery, genetic mutations in the tumor tissue can be searched for in order to predict whether a particular drug treatment is appropriate or not.
• Close cooperation with the Institute of Human Genetics and the Institute of Pathology at the Medical University of Innsbruck.

Chronic inflammatory bowel diseases

Ulcerative colitis

• It is classified as a chronic inflammatory bowel disease (IBD) and can spread from the rectum to the entire colon.
• Symptoms: bloody diarrhea, frequent bowel movements, cramp-like abdominal pain. The symptoms occur in episodes.
• Diagnosis: a colonoscopy including (stepwise) biopsy is necessary to confirm the diagnosis.
• Treatment: Ulcerative colitis is primarily treated conservatively/with medication (via the University Clinic for Internal Medicine/Gastroenterology). If the therapy is not effective, surgical treatment is performed. Surgical options include partial removal or complete removal of the colon while preserving continence (proctocolectomy with ilioanal pouch).

Crohn’s disease

• Also classified as a chronic inflammatory bowel disease (IBD) and can affect the entire gastrointestinal tract, with the last section of the small intestine (ileum) typically being affected.
• Symptoms: (non-bloody) chronic diarrhea, abdominal pain (often in the lower right abdomen), perianal fistulas, and abscesses
• Diagnosis: a colonoscopy including (staged) biopsy is necessary to confirm the diagnosis
• Treatment: Crohn’s disease is primarily treated conservatively/with medication (via the University Clinic for Internal Medicine/Gastroenterology). Surgical treatment is performed in cases of complications such as intestinal narrowing (stenosis, strictures) or perianal fistulas or abscesses. The procedures are performed using minimally invasive techniques and with a view to preserving as much of the intestine as possible.

Diverticulosis/diverticulitis

• Diverticulosis involves protrusions of the intestine (= diverticula). This is one of the most common changes in the gastrointestinal tract and its incidence increases with age (affecting approximately 65% of 85-year-olds). Inflammation of the diverticula is referred to as diverticulitis.
• Symptoms: Diverticulosis is usually asymptomatic. Diverticulitis causes symptoms such as left-sided abdominal pain, irregular bowel movements, and fever. Complicated diverticulitis can lead to abscesses, perforation, narrowing, or fistula formation. Blood vessels within the diverticula can bleed, causing rectal bleeding.
• Diagnosis: Colonoscopy, especially in acute diagnosis Imaging using CT scan
• Treatment: Depending on the severity of the diverticulitis, treatment is conservative (antibiotics), by puncturing abscesses, or surgical with resection in the case of large abscesses, perforations, or other complications such as fistulas.