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The first 25 slides, exactly as they appear. The full deck has 172 content slides.
General Surgery
Gastric Adenocarcinoma and Other Gastric Neoplasms (Except Gastrointestinal Stromal Tumors)
Built from Maingot's Abdominal Operations
What’s inside
14 sections · 172 slides
Overview
- Topics covered
Burden and Survival
How common stomach cancer is, who it strikes, and how many survive five years
- Tumour types that arise in the stomach
- Tissue of origin of gastric neoplasms
- Global burden of gastric cancer
- Falling incidence of invasive gastric cancer in the United States
- Declining incidence in industrialized nations
- United States incidence and mortality by ethnic group
- Five-year survival after diagnosis
- Five-year survival by stage at diagnosis
- Population screening and stage at diagnosis
Risk Factors
Environment, infection, smoking, weight, diet and inherited syndromes
- Environment versus inherited risk
- Environmental risk factors with proven evidence
- Ethnicity, presentation and response
- Helicobacter pylori as a carcinogen
- Evidence from the Japanese serology cohort
- Correa model of gastric carcinogenesis
- Steps of the Correa cascade
- Smoking as a causal factor
- Smoking risk by tumour site
- Obesity and cancer of the cardia
- Diet: fruit, vegetables, salt and nitrate
- Hereditary forms of gastric cancer
- Hereditary diffuse gastric cancer
- Managing a CDH1 mutation carrier
Clinical Presentation
Vague early symptoms, alarm features, and the physical signs of advanced disease
- Early symptoms of gastric cancer
- Alarm symptoms in dyspepsia
- The alarm symptoms
- How well alarm symptoms detect cancer
- Predictive value in rapid-access endoscopy
- Alarm symptoms and prognosis
- Physical signs in early and advanced disease
- Signs of peritoneal spread
Diagnosis and Staging
Endoscopy, imaging, fitness assessment and the TNM system
- Route to diagnosis
- Endoscopic ultrasound in staging
- Cross-sectional imaging
- Assessing fitness for treatment
- Preoperative laboratory testing
- Multidisciplinary review
- The TNM staging system
- Stage groupings of the TNM classification
- Definitions of the T, N and M categories
- Node and metastasis categories
- Depth of invasion behind the T category
- Selection for curative resection
- Options when cure is not possible
Chemotherapy and Radiation
What is added before and after the operation, and the evidence behind it
- Why surgery alone is not enough
- Rationale for preoperative treatment
- Preoperative radiation evidence
- MAGIC trial
- NCCN recommendation before surgery
- Adjuvant therapy after resection
- Adjuvant therapy by margin and stage
Principles of Resection
Margins, how much stomach to remove, staging laparoscopy and the laparoscopic approach
- Resection margins
- Choosing the extent of resection
- Proximal gastrectomy
- Staging laparoscopy before laparotomy
- Patients who do not need staging laparoscopy
- Laparoscopic gastrectomy for cancer
Lymph Node Dissection
Node stations, the D1 versus D2 argument, and endoscopic resection of early lesions
- Gastric lymph node stations
- N1 and N2 node groups
- D0, D1 and D2 dissections defined
- Extent of node clearance
- Node requirements under TNM
- The D1 versus D2 debate
- Findings of the two Western randomized trials
- Randomized trial results comparing D1 and D2 dissection
- Randomized trial results, continued
- Cochrane review of D1 versus D2
- Evidence since the Cochrane review
- Dutch trial at 15 years
- Current position on D1 versus D2
- Systems for staging lymph nodes
- Endoscopic submucosal resection
Distal Gastrectomy
The operation step by step, from exploration to transection of the stomach
- Exploration and incision
- Locating the tumour
- Sampling the para-aortic nodes
- Detaching the greater omentum
- Dissecting the anterior mesocolon
- Clearing the superior border of the pancreas
- Dividing the duodenum
- Closing the duodenal stump
- Burying the duodenal closure with Lembert sutures
- Completed invagination of the duodenal stump
- Node clearance after dividing the duodenum
- Dissecting the lesser omentum
- Dissection at the porta hepatis
- Ligating the left gastric vessels
- Marking the proximal resection line
- Transecting the stomach
Total Gastrectomy
How the proximal operation differs, and dividing the oesophagus
- Differences from distal gastrectomy
- Dividing the oesophagus
Restoring Continuity
Billroth II, Roux-en-Y, oesophagojejunal anastomosis and jejunal pouches
- Goals of reconstruction
- Jejunal interposition grafts
- Billroth II reconstruction
- Two reconstructions after distal gastrectomy
- Antecolic versus retrocolic limb
- Building the gastrojejunal anastomosis
- Roux-en-Y after distal gastrectomy
- Preparing the Roux limb
- Hand-sewn gastrojejunal anastomosis, step by step
- Jejunojejunostomy
- Reconstruction after total gastrectomy
- Roux-en-Y oesophagojejunostomy
- Hand-sewn oesophagojejunal anastomosis
- Hand-sewn oesophagojejunal anastomosis
- Completed hand-sewn oesophagojejunal anastomosis
- Stapled oesophagojejunal anastomosis
- Stapled oesophagojejunal anastomosis, placing the anvil
- Stapled oesophagojejunal anastomosis, firing and closure
- Finishing the reconstruction
- Jejunal pouch as a reservoir
Primary Gastric Lymphoma
The second commonest stomach cancer, and the one most often cured without an operation
- Gastric lymphoma in context
- Classifying lymphomas
- Histology of primary gastric lymphoma
- Distribution of histological subtypes in primary gastric lymphoma
- H. pylori and gastric lymphoma
- Diffuse large B-cell lymphoma
- MALT lymphoma
- Symptoms of gastric lymphoma
- Examination in suspected lymphoma
- Staging tests for gastric lymphoma
- Recommended staging protocol for primary gastric lymphoma
- Staging tests chosen by histology
- Searching beyond the stomach
- Staging systems for gastric lymphoma
- Ann Arbor staging system, Musshoff modification
- Stages of the modified Ann Arbor system
- Changing role of surgery in gastric lymphoma
- Treating MALT lymphoma
- Treating diffuse large B-cell lymphoma
Gastric Carcinoids
Neuroendocrine tumours of the stomach, and why the three types are treated differently
- Origin and definition of carcinoid tumours
- How common gastric carcinoids are
- Cell of origin and hormone product
- Three types of gastric carcinoid
- Classification of gastric carcinoids
- Type I gastric carcinoid
- Mechanism behind type I carcinoid
- Type II gastric carcinoid
- Type III gastric carcinoid
- Presentation of gastric carcinoid
- Presenting symptoms in a series of patients with gastric carcinoid
- Endoscopic diagnosis
- Laboratory workup
- Interpreting the laboratory results
- Characteristics of the three types of gastric carcinoid
- Staging small versus large tumours
- Treating type I and II carcinoids
- Surgery for type I and II carcinoids
- Metastatic gastric carcinoid
- Treating type III carcinoids
Summary
What to carry away from gastric adenocarcinoma, lymphoma and carcinoid
- Key points on gastric adenocarcinoma
- Key points on lymphoma and carcinoid
- Points to remember
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- Maingot's Abdominal Operations, 12th Edition