Small bowel tumours constitute about 3–6% of all gastrointestinal malignancies. An understanding of the natural history and prognosis of patients with small bowel cancer is hampered not only by the limited number of cases but also by the heterogeneity of the histology and the biology of the various tumour types. Each of these tumour sub-types has its own distinct clinical behaviour and, therefore, dictates a different treatment approach. There are no prospective randomized trials either that have elucidated the best diagnostic and therapeutic options for this rare condition. The management of small bowel tumours, therefore, remains a major diagnostic challenge. Physician’s suspicion and awareness are crucial in choosing appropriate diagnostic investigations for earlier detection of small bowel cancers and this may increase the chances of curative resections and possibly survival.

Oesophageal cancer is a morbid disease with a grim prognosis and is one of the common causes of cancer-related death worldwide. There have been a number of randomized trials and meta-analyses establishing the role of multi-modality treatment in resectable oesophageal cancer, primarily neoadjuvant chemotherapy and chemoradiotherapy. However, surgery remains the mainstay and an integral part of treatment in localized, non-metastatic oesophageal cancer. Concerns about surgery remain the high morbidity and mortality associated with the procedure. Several advances in surgical technique and perioperative care have considerably improved the perioperative outcomes of patients undergoing oesophagectomy, especially when performed in high-volume centres with a multi-disciplinary team caring for patients. These efforts have focused on enhanced recovery programmes, concentration of surgery in high-volume, experienced centres and by adopting different, potentially less morbid approaches to surgery. In this chapter, we describe the various issues related to surgery for oesophageal cancer including patient selection, pre-operative preparation, principles of surgical therapy, different surgical procedures for oesophageal cancer and some controversies of surgical technique and post-operative care.

The incidence of adenocarcinoma of the oesophagogastric junction (AEJ) has increased exponentially in the last few decades. This goes hand in hand with the rising incidence of Barrett oesophagus (BE), a well-known risk factor for AEJ. However, various strategies to prevent progression of Barrett oesophagus to adenocarcinoma have been largely ineffective and the role of screening and endoscopic surveillance remains controversial. PET CECT has developed into an important tool in the staging of adenocarcinoma of the oesophagogastric junction with a significant impact on management decisions. Surgery remains the mainstay of treatment of non-metastatic disease; however, some issues such as approach and extent of lymphadenectomy are still under debate. The addition of adjuvant strategies such as chemotherapy and chemoradiotherapy has improved the results of treatment. Innovative strategies probably at a molecular level are needed to gain any further improvement in results.

Patients with advanced GI malignancies have a plethora of symptoms – physical, psychological, social and spiritual. Addressing this suffering for both patient and family improves ‘quality of life’. The goals of palliative care address all above-mentioned issues and adequate evidence is available that introducing palliative care early into the trajectory of illness can even improve survival. Good symptom control is mandatory and should be reviewed as often as possible. For all medications oral route is preferred except in end-of-life care where subcutaneous route is preferred. Management of bowel obstruction at end of life can be done by subcutaneous medication without Ryle tube aspiration. The role of parenteral nutrition should be reviewed regularly and benefit should be clear. Every decision should involve patient and family and should be based on ethical principles. Psychological care by trained professionals ensures addressing all concerns at the right time. Breaking bad news should be done with empathy and proven techniques. Place of care should be patient choice, incumbent on physician to make it feasible. End-of-life care should be planned including advance directives. Bereavement care is part of palliative care and should continue till family members learn to move on.

Gastric cancer is currently the fourth most common cancer in the world, with the highest mortality rates in East Asia. Helicobacter pylori, advanced age, male sex, diet low in fruits and vegetables diet, preserved foods, pernicious anaemia, family history of gastric cancer, Ménétrier disease and familial adenomatous polyposis have been implicated in gastric cancer aetiopathogenesis. The management of gastric cancer is a multimodality approach. This chapter will address the nuances of management of early as well as locally advanced gastric cancer including the role of laparoscopic and minimally invasive surgery, the controversies revolving around D2 lymphadenectomy and optimal surgical resection in gastric cancer. This chapter will also focus on the various practice changing perioperative neoadjuvant and postoperative adjuvant modalities employed in the management of locally advanced gastric cancer.

The incidence of hepatocellular carcinoma (HCC) is increasing with advancing age worldwide. However, the mean age of patients with HCC is highest in Japan. Various modalities for the diagnosis, surgical management and treatment of HCC have been developed and established worldwide. Recently, pathological concept of early HCC has been accepted as small nodular and well-differentiated HCC less than 2 cm in greatest dimension with an obscure tumour margin. The hepatobiliary-phase image of Gd-EOB-DTPA-enhanced MRI is reported to improve the detection of early HCC. Furthermore, this hepatobiliary-phase image of Gd-EOB-DTPA-enhanced MRI can be used for the prediction of microscopic portal vein invasion of HCC. Since the microscopic vascular invasion and intrahepatic metastases, surrounding tumour, are diagnosed in about 20% of cases, anatomical hepatectomy is the most effective treatment for HCC of 2–5 cm in greatest dimension. Furthermore, treatment for viral infections is required to prevent a second primary HCC and a progression to cirrhosis. This report summarizes the current knowledge of diagnosis, pathology, role of surgery and outcomes of hepatectomy.

Five to 10% of all colorectal cancers (CRC) could be hereditary. Based on the clinical features and the underlying molecular mechanisms, hereditary colorectal cancer syndromes can be broadly divided into nonpolyposis and polyposis syndromes. These include hereditary non-polyposis colon cancer (HNPCC) due to germline mutations in the mismatch repair genes, familial adenomatous polyposis (FAP) due to mutations in the APC gene and a few other less common syndromes. Mutation carriers in HNPCC family have a lifetime risk of 70–80% for CRC and 50–60% for endometrial cancer (in female carriers), while in FAP, the risk is nearly 100% for CRC and 10–20% for thyroid cancer. Stomach, brain, skin and other cancers are seen less frequently. FAP is frequently associated with desmoid tumours and intra-abdominal fibromatosis and several other benign lesions. Once a syndromic diagnosis of hereditary GI cancer is made based on the personal and family history of cancer and other phenotypic features, the relevant genes are tested for germline mutations in the cancer affected proband using Sanger sequencing. Criteria for selecting individuals for genetic testing, methods of genetic testing and genetic counselling are highlighted. Clinical and investigative work-up and screening for HNPCC and FAP cases and healthy gene mutation carriers in these families are described. Evidence for efficacy and compliance of various methods for population-based screening for average-risk colorectal cancer is discussed.

Although surgery remains the only curative option for patients with localized advanced gastric cancer, most patients experience recurrence even after complete resection, leading to poor outcome. In order to improve survival outcomes various clinical trials have evaluated role of adjuvant chemotherapy and chemoradiotherapy; however, these studies have used different strategies and have produced conflicting results. The treatment in localized advanced cancer has become the standard of care worldwide; no single regimen has been accepted as the global standard. Based on the results of clinical trials, peri-operative chemotherapy is practiced widely in Europe while adjuvant chemoradiotherapy is the standard in North America and adjuvant chemotherapy is popular in East Asia. Despite these strategies, the outcome for patients with gastric cancer remains poor as most of these patients recur systemically. Survival of metastatic gastric cancer is among worst of most of the solid tumours. Five-year survival of metastatic gastric cancer is less than 5%. Even though targeted agents like trastuzumab and ramucirumab have shown a promising role the identification of newer prognostic and predictive factors is needed to improve treatment approaches and extend survival.