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INVESTIGATIONS
DIAGNOSTIC
OGD SCOPY RADIOLOGICAL ULTRASOUND, EUS/LUS CECT, PET
METASTATIC WORKUP
Chest X-ray Bone scan CT brain PET scan Laparoscopy Tumor markers- CEA, Carbohydrate antigen
GENERAL WORKUP
CBC & ESR LFT SE
Radiologic diagnosis
Distal GC
Proximal GC
Linitis plastica
EUS
CT SCAN
STAGING
Early gastric cancer Advanced gastric cancer Lauren classification- intestinal and diffuse type Borrmann classification TNM staging
Morphology---early stage
Morphology---early stage
Morphology---early stage
TNM CLASSIFICATION
T stage
T1-Mucosa and submucosa T2-Muscularis propria or subserosa T3-Serosa T4-Adjacent organs
M0- No distant metastasis M1- Distant metastasis(includes peritoneum and distant nodes)
IV
Ca stomach treatment
Ca stomach treatment
Adequate surgical resection is the only cure. Complete removal of gastric carcinoma with preferrably 5-6cm margin from the gross edge of the tumour.[5cm proximal and 2cm distal clearance]
Extent of gastrectomy is site dependent Distal 1/3rd Distal subtotal gastrectomy Middle 1/3rd Total gastrectomy Proximal 1/3rd Oesophago gastrectomy
Diffuse type Total gastrectomy Early gastric carcinoma involving mucosa only
Endoscopic submucosal resection laproscopic wedge resection.
D2 Gastrectomy
Structures removed
1. 2. 3. 4. 5. 6. 7. Stomach with the growth Omental bursa Entire greater omentum Lesser omentum Anterior layer of mesocolon Anterior pancreatic capsule Lymphadenactomy upto D2 station
Preoperative preparations
1. 2. 3. 4. 5. 6. 7. 8. Correction of anaemia Correction of nutritional status Fluid and electrolyte Assessment of cardiac, respiratory and renal status Arrange adequate blood Preoperative stomach wash Nil per oral Prophylactic antibiotics
Total gastrectomy
Stomach is removed en bloc including the tissues of entire greater omentum and lesser omentum Incision:
Long upper midline incision bilateral subcostal incision
careful examination for the extent of disease is performed assessing whether the disease is curable Transverse colon is completely seperated from greater omentum Subpyloric nodes are dessected and frst part of duodenum is divided Dessection of Hepatic nodes,supra pyloric nodes,left gastric artery,nodes at superiour aspect of pancreas and splenic hilum Seperation of stomach from spleen Division of oesophagus
Reconstruction
Oesophagojejunostomy Roux en Y Subtotal gastrectomy - Bilroth II, or Roux-en-Y gastrojejunostomy
Complications Early
1. 2. 3. 4. 5. Leakage of oesophagojejunostomy Duodenal stump leakage Biliary peritonitis Sepsis Haemorrhage
Late
Due to resection
1. Reduced Capacity 2. Dumping syndrome 3. Vit B12 Deficiency
Due to anastomosis
1. Loop obstruction 2. Alkaline Reflex Gastritis 3. Carcinoma of stump
Other Rx modalities
Radiotherapy Use is controversial. No. of radiosensitive tissue in the region of gastric bed limits the dose that can be given. Palliative treatment of painful bony mets.
Chemotherapy
Response well to combination cytotoxic chemotherapy. Neoadjuvant therapy improves outcomes. Combination of Epirubicin, Cisplatin and 5-FU or Capecitabine. Inoperable Cisplatin replaced by Oxyplatinin. 2nd line Rx Taxoterene combination
Relapse
Most common site Gastric Bed Inadequate removal of primary tumour. Self Expansible Metal Stents
7. Presence of Blumers shelf [Peritoneal mets in rectovesical / rectouterine pouch] 8. Presence of cutaneous nodules in umbilicus. [Sister Mary Joseph nodules] 9. Krukenberg tumour 10. N4 nodal status 11. Fixation to structures that cannot be removed.
Mx of inoperable cases
Chemotherapy Palliative surgery
Severe symptoms - Obstructions, bleeding, perforations
Palliative gastrectomy
Remove the tumour and reconstruct GIT. Need not be radical.
Anterior Gastrojejunostomy with Roux loop Divines exclusion procedure instead of removal of tumour, it is excluded with Bilroth II anastomoses. Inoperable tumours in cardia
Palliative intubation Stenting Other recanalisation
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