Toupet
How does the Nissen wrap work?
Chapter 41 / Stomach 275
Incomplete (around 200 ) posterior wrap (laparoscopic) often used with severe decreased esophageal motility
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Thought to work by improving the lower esophageal sphincter:
1.Increasing LES tone
2.Elongating LES 3 cm
3.Returning LES into abdominal cavity
In what percentage of |
85% (70%–95%) |
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patients does Lap Nissen |
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work? |
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What are the postoperative |
1. Gas-bloat syndrome |
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complications of Lap Nissen? |
2. |
Stricture |
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3. |
Dysphagia |
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4. |
Spleen injury requiring splenectomy |
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5. |
Esophageal perforation |
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6. |
Pneumothorax |
What is gas-bloat syndrome? |
Inability to burp or vomit |
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GASTRIC CANCER
What is the incidence? Low in United States (10/100,000); high in Japan (78/100,000)
What are the associated risk Diet—smoked meats, high nitrates, low factors? fruits and vegetables, alcohol, tobacco
Environment—raised in high-risk area, poor socioeconomic status, atrophic gastritis, male gender, blood type A, previous partial gastrectomy, pernicious anemia, polyps, Helicobacter pylori
276 Section II / General Surgery
What is the average age at the time of discovery?
What is the ratio of male to female patients?
Which blood type is associated with gastric cancer?
What are the symptoms?
What are the most common early symptoms?
What is the most common symptom?
What are the signs?
What does the patient with gastric cancer have if he or she has proximal colon distension?
What is the symptom of proximal gastric cancer?
What is a Blumer’s shelf?
What is a Virchow’s node?
60 years
3:2
Blood type A (there is an “A” in gastric but no “O” or “B” gAstric type “A”)
“WEAPON”: Weight loss Emesis Anorexia
Pain/epigastric discomfort Obstruction
Nausea
Mild epigastric discomfort and indigestion
Weight loss
Anemia, melena, heme occult, epigastric mass (in advanced disease), hepatomegaly, coffee-ground emesis, Blumer’s shelf, Virchow’s node, enlarged ovaries, axillary adenopathy
Colonic obstruction by direct invasion (rare)
Dysphagia (gastroesophageal junction/cardia)
Solid peritoneal deposit anterior to the rectum, forming a “shelf,” palpated on rectal examination
Metastatic gastric cancer to the nodes in the left supraclavicular fossa
What is Sister Mary Joseph’s sign?
What is a Krukenberg’s tumor?
What is “Irish’s” node?
What is a surveillance laboratory finding?
What is the initial workup?
Chapter 41 / Stomach 277
Periumbilical lymph node gastric cancer metastases; presents as periumbilical mass
Gastric cancer (or other adenocarcinoma) that has metastasized to the ovary
Left axillary adenopathy from gastric cancer metastasis
CEA elevated in 30% of cases (if , useful for postoperative surveillance)
EGD with biopsy, endoscopic U/S to evaluate the level of invasion, CT of abdomen/pelvis for metastasis, CXR, labs
What is the histology? Adenocarcinoma
What is the differential diag- Adenocarcinoma, leiomyoma, leiomyosar-
nosis for gastric tumors? |
coma, lymphoma, carcinoid, ectopic pan- |
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creatic tissue, gastrinoma, benign gastric |
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ulcer, polyp |
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What are the two histologic |
1. |
Intestinal (glands) |
types? |
2. |
Diffuse (no glands) |
What is the morphology? |
Ulcerative (75%) |
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Polypoid (10%) |
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Scirrhous (10%) |
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Superficial (5%) |
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Are gastric cancers more common on the lesser or greater curvatures?
What is more common, proximal or distal gastric cancer?
Which morphologic type is named after a “leather bottle”?
How do gastric adenocarcinomas metastasize?
Lesser (“less is more”)
Proximal
Linitis plastica—the entire stomach is involved and looks thickened (10% of cancers)
Hematogenously and lymphatically
278 Section II / General Surgery |
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Which patients with gastric |
1. |
Distant metastasis (e.g., liver metastasis) |
cancer are NONoperative? |
2. |
Peritoneal implants |
What is the role of |
To rule out peritoneal implants and to |
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laparoscopy? |
evaluate for liver metastasis |
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What is the genetic |
P53 |
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alteration seen in 50% of |
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patients with gastric cancer? |
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How can you remember P53 for gastric cancer?
What is the treatment?
What operation is performed for tumor in the:
Antrum?
Midbody?
Proximal?
What is a subtotal gastrectomy?
Gastric Cancer GC P53; or, think: “GCP . . . 53”—it sings!
Surgical resection with wide ( 5 cm checked by frozen section) margins and lymph node dissection
Distal subtotal gastrectomy
Total gastrectomy
Total gastrectomy
Subtotal gastrectomy 75% of stomach removed
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Chapter 41 / Stomach 279
What is a total gastrectomy? Stomach is removed and a Roux-en-Y limb is sewn to the esophagus
Common |
Roux |
limb |
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bile duct |
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What type of anastomosis? |
Billroth II or Roux-en-Y (never use a |
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Billroth I) |
When should splenectomy |
When the tumor directly invades the |
be performed? |
spleen/splenic hilum or with splenic hilar |
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adenopathy |
Define “extended lymph |
Usually D1 and D2: |
node dissection.” |
D1 are perigastric LNs |
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D2 include: splenic artery LNs, |
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hepatic artery LNs, anterior |
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mesocolon LNs, anterior pancreas |
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LNs, crural LNs |
What percentage of patients are inoperable at presentation?
What is the adjuvant treatment?
What is the 5-year survival rate for gastric cancer?
10% to 15%
Stages II and III: postoperative chemotherapy and radiation
25% of patients are alive 5 years after diagnosis in the United States (in Japan, 50% are alive at 5 years)