← All decks
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
- References
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- Maingot's Abdominal Operations, 12th Edition