Squamous cancer of the oesophagus

Squamous oesophageal cancer, also called squamous cell carcinoma of the oesophagus, squamous cell carcinoma of the oesophagus (SOC), or oesophageal carcinoma, is a type of cancer that can affect any part of the oesophagus, but usually occurs in the upper or middle third of the oesophagus.

It appears in adulthood and senescence, with the peak incidence being around 60-70 years of age, and with a higher prevalence in men. Although it is a multifactorial pathology, smoking and alcohol abuse are risk factors.

It is usually asymptomatic until advanced stages. Symptoms include pain and inability to swallow (earliest), weight loss, hoarseness, cough or chest pain.

Diagnosis is made by endoscopy and biopsy, as well as by CT and endoscopic ultrasound and, very often, PET-CT.

Treatment consists of total or near-total resection of the oesophagus, either by abdominal and thoracic approach alone or by abdominal, thoracic and cervical approach. If possible, surgery should be performed by minimally invasive techniques as they improve postoperative outcomes (laparoscopy and thoracoscopy).

At present, it is very common for patients to receive treatment prior to surgery to improve survival, so-called "neoadjuvant" treatment.

Adenocarcinoma of the oesophagus

Adenocarcinoma of the oesophagus is a cancer that starts in the glandular cells in the lining of the oesophagus, which produce and release secretions such as mucus. This type of cancer most often occurs near the junction with the stomach, in the lower end of the oesophagus.

Onset occurs in adulthood and senescence, particularly around 50-60 years of age, and is more prevalent in men. It may be asymptomatic until advanced stages, or present with symptoms such as swallowing problems and weight loss.

Its main pathological precursors are chronic gastro-oesophageal reflux disease (GORD) and Barrett's oesophagus (BE) as a consequence.

Diagnosis, as in squamous cell carcinoma, is based on clinical findings and is supported by complementary examinations, mainly endoscopy and biopsy, echo-eenoscopy, thoracoabdominal CT and PET-CT. Curative treatment is based on surgical resection as long as it is localised and there is no distant disease. It is also common for the patient to receive treatment prior to oncological surgery ("neoadjuvant").

 

Barrett's oesophagus

Barrett's oesophagus (BE) is a condition in which the lining of the oesophagus changes and becomes like that of the small intestine (intestinal dysplasia). While the lining of a healthy oesophagus is pale and shiny, in Barrett's oesophagus the tissue is red and velvety.

This dysplasia (abnormality in the development of tissue) is common in people with gastro-oesophageal reflux. Although it may be asymptomatic, symptoms are related to the latter condition, with frequent burning, difficulty swallowing and chest pain.

The causes of Barrett's oesophagus are unclear, but overweight and smoking, and undoubtedly severe and persistent gastro-oesophageal reflux, have been identified as risk factors.

Diagnosis is made by endoscopy to look for tissue changes and biopsy.

Finally, treatment will vary depending on the type of tissue seen in the biopsy.

If there are no obvious tissue changes, a dedicated treatment to improve gastro-oesophageal reflux will be performed.

If the metaplastic tissue starts to become aggressive to varying degrees, local therapy (mucosectomy, radiofrequency, cryotherapy) or even surgery may be necessary.

Oesophageal diverticula

Diverticula are small sacs that can appear in the wall of the digestive tract, in this case in the oesophagus. When they consist of all the layers of the oesophagus, they are called true diverticula and are usually caused by traction, usually in the middle third of the oesophagus. When they consist only of mucosa and submucosa ("pseudodiverticula"), they are usually caused by increased pressure in the lumen of the oesophagus and are usually located in the upper or lower third of the oesophagus.

Diverticula may be asymptomatic or cause swallowing problems and regurgitation (expulsion of food or fluid without nausea or contractions of the abdomen).

Diagnosis can be made by upper endoscopy or by barium transit radiography. The rise of CT scans has led to an increase in diagnosis by these techniques. 

In terms of treatment, in most cases, diverticula do not require treatment, although surgery may sometimes be necessary.

Zenker's diverticulum

Zenker's diverticulum, also called pharyngo-oesophageal or hypopharyngeal diverticulum, is the most common variety of oesophageal diverticulum. It usually occurs in the postero-lateral aspect of the junction between the larynx and oesophagus, and its prevalence increases from the age of 50 to 80 years.

Although it may be asymptomatic, symptoms include difficulty swallowing, noisy swallowing, halitosis (bad breath), sialorrhoea (inability to hold saliva in the mouth) and irritative cough. In more advanced stages, weight loss and lung disease may occur.

If the condition is suspected on examination, the definitive test is the barium transit study.

Treatment of Zenker's diverticulum can be by surgical treatment of diverticulectomy (removal of the diverticulum), coupled with myotomy (section of muscle used to access tissues or relieve sphincter constriction), or by endoscopic surgery.

Achalasia of the oesophagus 

It is a motor disorder of the oesophagus characterised by the absence of relaxation of the lower oesophageal sphincter during the swallowing process, which prevents the correct passage of the food bolus from the oesophagus to the stomach.

The lower oesophageal sphincter is a ring of lower oesophageal muscle that keeps its junction with the stomach closed, making it difficult for food and stomach acid to flow back into the oesophagus. When swallowing, the sphincter relaxes, allowing food to pass through.

Achalasia can occur at any age, but usually begins imperceptibly between the ages of 20 and 60.

Achalasia of the oesophagus is usually caused by dysfunction of the nerves in the area (denervation), which can be caused by infections, tumours or autoimmune causes.

Symptomatology of achalasia of the oesophagus may be based on difficulty in swallowing, chest pain, regurgitation, and in case of aspiration, coughing, lung abscesses and respiratory infections. In severe cases, weight loss may also occur.

This pathology is suspected on clinical grounds and upper gastrointestinal endoscopy is necessary to differentiate it from others such as oesophageal cancer. However, manometry is essential for diagnosis.  

Oesophageal manometry is a test that measures the rhythmic contractions of the oesophageal muscles during swallowing. In addition to whether the contractions are normal, the strength of the oesophageal muscles and whether or not there are problems in the sphincter can be assessed.

In terms of treatment, this can be either surgical or non-surgical. Non-surgical treatments are recommended for older people or people with health problems, while surgeries are recommended to a greater extent for young people, as they are more effective. 

Non-surgical treatments include pneumatic sphincter dilatation, Botox and drug therapy.

Pneumatic dilatation involves the insertion and inflation of a balloon into the oesophageal sphincter to enlarge the opening.

Botox is a muscle relaxant that can be applied to the sphincter by endoscope. It is recommended for those who are not good candidates for surgery or pneumatic dilation.

In the case of pharmacological treatment, muscle relaxants such as nitroglycerin will be prescribed before meals. It is also a unique option for people who are not candidates for the other types of treatment.

Achalasia surgery consists of Heller myotomy, generally performed by a minimally invasive approach. It consists of sectioning the lower oesophageal sphincter musculature to allow its continuous connection, using an anti-reflux technique.

In recent years, the endoscopic alternative to this procedure has emerged strongly. A section of the lower oesophageal sphincter musculature is also performed but accessed through the oesophageal lumen, with very good results (POEM).

Oesophageal peptic stricture

Peptic oesophageal stricture or benign oesophageal stricture is a narrowing of the oesophagus caused by ongoing damage to the oesophageal wall by gastric juice. It results from gastro-oesophageal reflux disease that has been poorly treated for many years.

Stenosis occurs when erosion of the oesophagus causes the tissue to be replaced by fibrous tissue, which shrinks over time. 

The clinical picture of stenosis is difficulty in swallowing, regurgitation, chest pain, painful swallowing and, as a result, malnutrition and weight loss.

Diagnosis is made by endoscopy and biopsy, or barium oesophagogram to identify the variable segment of the oesophagus.

Treatment is usually by balloon dilatation of the oesophagus. Associated therapy for GERD, either medical or surgical, is necessary.

Exceptionally, surgery may be necessary.

Stomach

The stomach is a pouch-like organ in the upper part of the abdominal cavity whose primary function is to digest food. The lower oesophageal sphincter at the top of the stomach controls the passage of food into the stomach and prevents the contents from rising. The pylorus is the final part of this organ and is a sphincter that controls the passage of almost completely digested food into the rest of the digestive tract.

The stomach may suffer from the following conditions:

Oesophago-gastric junction cancer

This is the cancer that appears at the junction between the oesophagus and the stomach, classically known as the cardia.

This type of cancer has a higher incidence in men, appears at around 50-70 years of age and suffering from oesophageal reflux or Helicobacter pylori infection are risk factors.

The main symptoms include swallowing problems, breathing difficulties, weight loss, pain, hoarseness, hiccups or bleeding.

If this type of cancer is suspected, the diagnosis is made by upper endoscopy with biopsy and probably echoendoscopy. At least a CT scan of the chest and abdomen and sometimes a PET-CT scan and staging laparoscopy will be necessary.

Treatment is surgical, removing the area affected by the tumour, but it may be necessary to apply preoperative treatment beforehand (neoadjuvant treatment).

Siewert (Types 1, 2 and 3)

The Siewert-Stein classification is a classification of cancers of the cardia, the part where the oesophagus joins the upper opening of the stomach. In this area we can speak of 3 types of cancer according to their location:

• Type I (Adenocarcinoma of the distal oesophagus): The centre of the tumour is between 5 cm and 1 cm above the line where oesophagus and stomach meet.
• Type II (Carcinoma of the cardia or cardia cancer): The tumour is located between 2 cm and 1 cm from the oesophago-gastric junction line.
• Type III (Subcardial carcinoma or cancer): Found 2 cm below the junctional line and up to 5 cm inside the upper part of the stomach.

Siewert type I adenocarcinomas will be treated according to the rules for adenocarcinomas of the distal oesophagus. Siewert type III adenocarcinomas are treated according to the rules for adenocarcinoma of the stomach. The classification of Siewert type II is more controversial.

 

Gastric cancer

Gastric or stomach cancer is a type of adenocarcinoma, a cancer that starts in the cells of the stomach lining. It is caused by mutations in DNA but has risk factors such as high salt or smoked diets, the presence of Helicobacter pylori and a personal and family history of gastric cancer or digestive conditions.

The main symptoms of gastric cancer are as follows:

• Bloating after meals.
• Easy satiety.
• Persistent and intense burning.
• Indigestion.
• Stomach pain.
• Nausea and/or vomiting.
• Slimming.

The diagnosis of stomach cancer is made by endoscopy and biopsy), echoendoscopy and computed tomography of the chest and abdomen. Staging laparoscopy may be necessary.  

Stomach cancer is treated surgically and has several options, often after neoadjuvant chemotherapy.

Removal of the tumour, part of the stomach (partial gastrectomy) or all of the stomach (total gastrectomy) may be performed. It is often necessary to remove the locoregional lymph nodes to determine if cancer is present (lymphadenectomy).

Surgery can pose a risk of bleeding or infection and the removal of part or all of the stomach can lead to digestive problems.

Supportive treatments such as drugs, chemotherapy or radiotherapy may be added to surgery.

The prognosis for this type of cancer depends on the stage of the cancer.

Gastric gist 

Gastrointestinal stromal tumour, or GIST, is a type of soft tissue sarcoma. This cancer affects the connective tissue of the gastrointestinal tract and its adjoining structures.

In these cases, the interstitial cells of Cajal (ICC), nerve cells that are responsible for contributing to the movement of the digestive organs, become cancerous. In 90% cases it is considered to be due to a mutation, but lifestyle, as in other cancers, also increases the risk.

It is equally prevalent in both sexes and usually occurs around the age of 50 years, in 55% of cases in the stomach.

It is usually asymptomatic until advanced stages, although it can cause symptoms such as chronic abdominal pain, intestinal obstruction and digestive hermorrhagia.

They are usually diagnosed by abdominal CT scan and upper gastrointestinal endoscopy.

The most common treatment is surgical removal. Postoperative chemotherapy treatment may be required if the tumour is very large or aggressive, and occasionally preoperative chemotherapy if direct surgery is deemed unsafe.

Neuroendocrine tumour of the stomach

Neuroendocrine tumours of the stomach are a type of cancer that begins in certain specialised cells in the stomach that have similar features to nerve and hormone-producing cells.

These are rare cancers that may be asymptomatic in early stages. In later stages they can cause pain, fatigue, weight loss or even diarrhoea and redness of the skin.

In the case of clinical suspicion or incidental endoscopic findings of a neuroendocrine tumour of the stomach, the diagnosis is mainly made by urine and blood tests, upper endoscopy, abdominal CT and abdominal CT with special radiological markers.

Treatment in these cases is mainly surgical to remove the tumour, although there are special cases that require individualised treatment.

Hiatus hernia

A hiatal hernia, or hiatal hernia, is a hernia that occurs when the upper part of the stomach protrudes through the diaphragm. The diaphragm, the muscle that acts as a separator between the chest and abdomen, has a small opening to allow the oesophagus to pass through. As the pressure inside the abdomen is greater than in the thorax, the stomach has a tendency to migrate into the abdomen and cause this pathology.

Small hernias may be asymptomatic but larger hernias may produce the following symptoms:

• Reflux.
• Regurgitation of food.
• Heartburn.
• Chest pain or abdominal pain.
• Shortness of breath.
• Swallowing problems.
• Flatulence.
• Halitosis and/or dry cough.
• Vomiting and/or bloody stools.

In the most severe cases, the stomach can become completely strangulated in the hernial sac and life-threatening.

Although many people confuse hiatal hernia with oesophageal reflux disease, they are not the same problems, although they may be closely related.

Diagnosis of hiatal hernias is mainly made by upper gastrointestinal endoscopy, but simple radiography may raise suspicion. In large hernias, a CT scan of the chest and abdomen is essential. If it is suspected that the patient has gastro-oesophageal reflux and the hernia is small, pH metry and oesophageal manometry will be performed.

In many cases hiatal hernias do not require surgery. When associated with reflux that can be controlled with medication, this is usually sufficient.

In cases of large hernias with risk of strangulation, or when there is clinical evidence of chest compression, it will be necessary to operate, generally by a minimally invasive approach. If the patient has gastro-oesophageal reflux and it is not controllable with medication, surgery is also necessary.

 

Esophageal Gastric Reflux Disease (GERD) 

Esophageal Gastric Reflux Disease (GERD) is a condition that occurs when stomach acid frequently backs up into the esophagus. This acid backflow can irritate and inflame the oesophageal tissue.

When swallowed, the lower oesophageal sphincter relaxes and allows food and liquids to pass into the stomach and then closes again to prevent reflux. If the sphincter, which acts as a gateway, is abnormally relaxed or weakened, gastric acids can rise.

Risk factors for GERD include pregnancy, a hiatal hernia, obesity, smoking, or the use of certain drugs. 

Some symptoms of this pathology are heartburn, chest pain, difficulty swallowing, regurgitation or a feeling of a lump in the throat.

If it occurs at night, chronic cough, asthma, laryngitis or sleep disorders may also be seen. 

Complications of GORD are for example oesophageal ulcers, Barrett's oesophagus, oesophageal stricture (or stricture) and oesophageal adenocarcinoma.

The diagnosis of oesophago-gastric reflux can be made in several ways. Firstly, an upper endoscopy may be performed to take a biopsy or to check for oesophagitis (inflammation).

Another test that can be performed is an ambulatory acid (pH) probe test, by inserting a probe to monitor when and how long acid is regurgitated (pHmetry).

Oesophageal manometry is not by itself diagnostic of GORD, but is often performed to find out how the oesophageal muscles work and whether they have been affected by the chronic presence of acid.

Finally, a barium X-ray of the upper gastrointestinal tract may also be performed.

In milder cases, stomach acid neutralising drugs, drugs that decrease acid production or drugs that block acid production and help heal the oesophagus can be taken.

In moderate cases, drugs such as omeprazole or those that strengthen the lower oesophageal sphincter may be prescribed.

In cases where the pharmacological option does not help, surgery is performed, which is called fundoplication.

In fundoplication, the surgeon wraps the upper part of the stomach around the sphincter of the oesophagus to tighten the muscle and reduce and prevent reflux. 

In recent years, other alternatives to traditional surgery, such as the implantation of the LYNX system or even endoscopic treatment, have been developed. 

 

Duodenum

The duodenum is the first part of the small intestine, located between the end of the stomach and the jejunum. The duodenum can suffer from the following pathologies:

Duodenal diverticulum

Duodenal diverticula, from the Latin diverticulum (deviation from the path), are sacculations of the mucosa and submucosa of the duodenum (part of the small intestine that connects the stomach to the jejunum), which herniate due to muscular defects.

They are more common in females and around the fifth or sixth decade of life. They are usually single and generally asymptomatic. In cases where symptomatology occurs, patients may present with epigastric pain, vomiting and duodeno-biliary reflux.

Complications of duodenal diverticula include bleeding, perforation, anaemia, intestinal obstruction, malabsorption of nutrients, pancreatitis or jaundice (yellowing of the tissue).

They are usually diagnosed in the course of an upper endoscopy or by an imaging test such as an abdominal CT scan.

Although they usually do not cause symptoms and treatment is usually not necessary, sometimes it may be necessary to prescribe antibiotics or even remove the diverticulum by surgery.

Duodenal cancer 

Duodenal cancer occurs when malignant cells form in the duodenum. The most common type is adenocarcinoma, which means that the tumour occurs in the most superficial mucosal epithelial cells.

Although the cause of its occurrence is unclear, there are several risk factors for its development such as hereditary colon cancer not associated with polyposis, familial adenomatous polyposis and other forms of polyposis, Crohn's disease, long-term untreated celiac disease or cystic fibrosis. 

The main symptoms of duodenal cancer are abdominal pain, weight loss, fatigue, anaemia, blood in the stool, vomiting, diarrhoea, intestinal obstruction and jaundice.  

The diagnosis of duodenal cancer is usually made by upper endoscopy, usually in association with echoendoscopy, abdominal and thoracic computed tomography, abdominal magnetic resonance imaging and PET (positron emission tomography).

Treatment of duodenal cancer is surgical, with removal of the tumour, which may even require resection of part of the pancreas. Postoperative chemotherapy is usually necessary.

Duodenal perforation

Duodenal perforation occurs when a duodenal ulcer perforates. The main symptom of duodenal perforation is a sudden, severe pain in the centre of the abdomen, which may radiate to the shoulders. Because of the pain, the affected person may become immobile.

Classically it was diagnosed by abdominal X-rays, but nowadays it is diagnosed by abdominal CT scan. Treatment is surgical and urgent. A procedure other than simple suturing of the ulcer and lavage of the abdominal cavity, usually by a minimally invasive approach, is now rare, unless the patient is very ill at the time of surgery. Subsequently, the presence of H. pilory infection should be investigated and treated if present.

Small and large intestine

The intestine is the portion of the digestive tract between the stomach and the anus. It is divided into the small intestine and the large intestine.

The small intestine has three parts, the duodenum, jejunum and ileum, although we generally refer to the jejunum and ileum. The large intestine consists of the cecum, ascending colon, transverse colon, descending colon and sigma. The rectum is the final part of the large intestine and is the final reservoir for faeces. At the junction between the small and large intestine is the cecal appendix.

Its function is to do most of the absorption of nutrients, absorb water and transport faeces to the anus.

The intestines may suffer from the following conditions:

Intestinal diverticula

Diverticula are small pouches that arise in the wall of the digestive tract, and move outwards due to increased endoluminal pressure. They are much more common in the left side of the colon and sigma, but can occur throughout the small and large intestine. They are not made up of all the layers of the bowel wall, which is why they are called "pseudodiverticuli".

Colon diverticula are very common from the 5th decade of life onwards, and most of the time they are asymptomatic. When they do show symptoms, we are dealing with diverticular disease, which can manifest itself as haemorrhage or inflammation, the so-called diverticulitis.

In most cases, acute diverticulitis of the colon is a mild condition that can be treated with only digestive rest, antibiotics and/or anti-inflammatory drugs. However, when the colon ruptures, abscesses (pockets of pus) may form or life-threatening peritonitis may develop with faeces in the abdominal cavity. In these cases it may be necessary to place external drains, at best, or to perform aggressive surgery, removing the diseased segment of large bowel and performing colostomies. In recent years, direct anastomosis and laparoscopic techniques are increasingly used, including multi-stage surgery to avoid stomas.

 

Meckel's diverticulum

Meckel's diverticulum is a very common congenital anomaly. It occurs when the junction between the small intestine and the umbilical cord does not close completely during foetal development. As a result, a small pouch or diverticulum appears in the intestine. This is a true diverticulum, as it is made up of all the layers of the intestine.

In most cases they do not usually cause problems, but they can become infected (diverticulitis) or bleed, due to ulceration of the mucous membrane inside them.

Treatment of Meckel's diverticulum consists of surgical removal of the diverticulum under general anaesthesia, usually by laparoscopic approach.

Haemorrhagic bowel lesions

Haemorrhagic bowel injury is caused by bleeding in the intestine due to polyps, tumours, Crohn's disease, Meckel's diverticulum or pulsatile intestinal diverticula or abnormalities in the intestinal blood vessels (which occur mostly in older age and with chronic kidney and heart disease). 

The diagnosis of haemorrhagic lesions and the latent cause is made by endoscopy and imaging tests. When the origin is in the middle tract, it can be very difficult to reach an accurate diagnosis, even with methods such as capsule endoscopy or deep endoscopy.

Treatment depends on the cause of the bleeding and its location. In the case of small abnormalities in the intestinal blood vessels in areas accessible to the therapeutic endoscope, endoscopic cauterisation is performed.

In the case of very large anomalies or a clear tumour, surgery will be performed to remove the affected area.

In cases of ulcers or inflammation due to Crohn's disease, drug therapy may be tried. 

Intestinal Gist

Intestinal Gist (Gastrointestinal Stromal Tumour) is a type of soft tissue sarcoma. Between 20 and 30% of these cancers occur in the small intestine, and are due to mutations and alterations in cell generation.

In early stages they may be asymptomatic or cause very mild discomfort. In later stages they may cause a feeling of fullness, pain, bleeding or black stools, nausea and constipation. 

Diagnosis will usually be made by abdominal CT scan.

Treatment will be removal of the tumour mass, with or without adjuvant treatment.

 

Neuroendocrine tumour of the intestine

Neuroendocrine tumour of the intestine is a type of cancer that originates from neuroendocrine cells in the mucosa of the intestine. Some tumours can release hormone-like substances, and in cases of carcinoid syndrome, this is caused by an excess of serotonin which causes vasodilation. In these cases, these tumours are referred to as "carcinoid tumours" after similarity to the clinical picture.

Vasodilatation leads to increased blood flow, resulting in tachycardia, facial flushing (reddening of the skin and a feeling of warmth), wheezing and severe diarrhoea. These are some of the symptoms of this type of tumour. 

Diagnosis is made by urine and blood tests and imaging tests, mainly abdominal CT and abdominal CT with special contrasts.

In terms of treatment, surgery to remove the tumour is the main treatment, often accompanied by supportive cancer therapies. 

 

Crohn's disease

Crohn's disease is a chronic intestinal pathology based on inflammation of some part of the digestive system, from the mouth to the anus. However, the most affected point tends to be the ileum, the most distal region of the small intestine.

It tends to appear mainly in people between the ages of 15 and 35 and although its cause is not yet clear, an autoimmune basis is suspected.

Signs of Crohn's disease include cramping abdominal pain, fatigue, fever, poor appetite, discomfort during bowel movements, diarrhoea and unintentional weight loss. Sometimes the presence of recurrent or complex perianal fistulas precedes the rest of the disease by years. In addition to intestinal symptoms, patients may present with extraintestinal symptoms.

Treatment is initially pharmacological, but surgery may be necessary in the case of aggressive forms. Because the bowel segments are often highly inflamed and adherent to each other, laparoscopic resection is not the most common but, if it can be done, it has better results.

Intestinal occlusion

Intestinal occlusion is a closure of the intestine that completely or partially prevents intestinal transit. When an obstruction occurs, the proximal part of the bowel dilates and may become perforated.

The causes of intestinal occlusion are very varied, although the most frequent cause is the presence of adhesions as a consequence of any previous surgery. Other causes of obstruction include a complicated hernia, an obstructing tumour and a foreign body obstructing the lumen.

The most characteristic symptom of intestinal obstruction is the absence of transit, which is often associated with abdominal distention and vomiting. The presence of severe pain and tenderness may point to a complicated obstruction that will always require urgent surgical intervention.

The history and physical examination will guide the diagnosis, although nowadays an abdominal CT scan is practically obligatory to confirm the diagnosis and guide both medical and surgical treatment.

Treatment will depend on the cause of the obstruction and the possible presence of complications. If the cause is adrenal and the condition is not complicated, conservative treatment will be the initial treatment, with placement of a nasogastric tube, digestive rest and fluid therapy, in addition to the administration of water-soluble radiological contrast through the tube or by drink, achieving very high success rates. Only in case of failure, surgery is indicated, preferably by a minimally invasive approach.

If the obstruction is due to a hernia, surgery will be necessary almost 100% of the time. It will be necessary to repair the hernia and assess the viability of the bowel.

If the obstruction is due to an endoluminal foreign body, this is usually the treatment of choice, although in selected cases powerful laxatives may be used.

If the cause is an obstructing tumour, it is possible to place stents in the lumen of the large bowel to defer surgery to a laparoscopic approach, but this will depend on the patient's condition and the location of the tumour.