Stomach and Duodenum—Gastric Cancer
Concept
Will likely present as a large ulcer and biopsy proven malignancy. Patient may not be candidate for anything but palliation. Be prepared to describe your work-up and operation. Remember that gastric lymphoma is a different beast from gastric cancer.
Way Question May be Asked?
“A 63 y/o man presents to ED with UGIB. After stabiliza- tion, an EGD is performed that reveals a large ulcer on the greater curvature, biopsies return with well-differentiated adenocarcinoma. What do you do?” May also present as a non-healing ulcer with pain, perforation, obstruction, or in work-up for melena or heme + stool.
How to Answer?
History
Risk factors Weight loss
Abdominal distension
Physical Exam
Evidence of weight loss/malnutrition Palpable abdominal mass
Prior surgical scars
Lymphadenopathy (supraclavicular, periumbilical) Rectal exam (Blummer’s shelf)
Labs
Full laboratory panel
Diagnostic Studies
UGI EGD
CT scan (to r/o metastatic disease)
Can consider laparoscopy at onset of operation (r/o liver mets/carcinomatosis)
Measure basal acid output (achlorhydria assoc. with malignancy)
Location of tumor:
(1) Tumors in antrum/distal third of stomach → radi- cal subtotal gastrectomy involving 3 cm of first part of duodenum, hepatogastric omentum, greater omentum, and a D1 resection (immediately adja- cent perigastric lymph nodes)
(2) Tumors in corpus/middle third of stomach → subto- tal or total depending on size of tumor
(3) Tumors in proximal third → total gastrectomy, reconstruction with Roux-en-Y
(4) Palliation → total gastrectomy (not gastroenteros- tomy!)
Comments on Surgery
Resection with 5 cm margins (if within 5 cm of GE junction, needs total gastrectomy
Only resect spleen if gross tumor involvement No evidence for resection of hepatic metastases Check margins of resection by frozen section
En bloc resection of any directly invaded organ (spleen, tail of pancreas, kidney), except CBD or head of pancreas
No evidence for Japanese style D2 resection
Should perform D1 resection which includes: suprapy- loric, infrapyloric, and nodes along the greater and lesser curvature
Can consider adjuvant and neo-adjuvant treatments
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Don’t forget vagotomy (anastomosis is ulcer producing procedure)
Don’t forget different types of reconstruction (BII if cancer)
Common Curveballs
Anastomotic cancer 20 years after prior gastric surgery Pt will have postoperative anastomotic bleed (especially
if didn’t do vagotomy) Pt will have leak post-op Pt will be malnourished
Complication of gastric surgery post-op:
Dumping syndrome—conservative measure first, then Roux-en-Y
Postvagotomy diarrhea—conservative measure first, then reversed jejunal segment
Alkaline reflux gastritis—confirm by hepatobiliary scan, conservative measure first, then RY gastro- jejunostomy
Anastomotic bleed—EGD, suture ligation if EGD fails
Afferent loop syndrome—side to side jejunojejunos- tomy
Gastroperesis—conservative measure first, comple- tion antrectomy or gastrectomy, depending on prior surgery, may be necessary
Ulcer will be high on greater curve near GE junction
Tumor will have penetrated into surrounding structures (spleen, kidney, distal pancreas)
Being asked the difference between R1, R2 and R3 nodes
Pathology will be lymphoma
May actually be esophageal cancer and need traditional Ivor-Lewis Resection
Pt will present later with evidence of metastatic dis- ease/obstruction
Celiac node will be positive → “what does that mean”
Pt will have peritoneal mets → how to palliate pt Treatment for duodenal stump leak (if early, duodenos-
tomy, drains, NPO, TPN)
(if late/abscess, CT guided drain, NPO, TPN)
Strikeouts
Resecting hepatic metastases
Performing less than total gastrectomy for tumor < 5 cm from GE junction
Not staging pt appropriately
Discussing laparoscopic resection of gastric cancer Not checking margins of resection by frozen section Offering any therapy besides surgery for “cure”
Discussing photodynamic therapy Discussing endoscopic mucosal resections
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