Dr. E. J. ArteenF.R.C.S

General & Colorectal Consultant Surgeon

ANATOMYANATOMY::

The stomach is J-shaped. The stomach has two surfaces (the anterior & posterior), two curvatures (the greater & lesser), two orifices (the cardia & pylorus). It has fundus, body and pyloric antrum.

BLOODBLOOD SUPPLYSUPPLY::

a. The left gastric arteryb. Right gastric arteryc. Right gastro- epiploic arteryd. Left gastro- epiploic arterye. Short gastric arteries

The corresponding veins drain into portal system. The lymphatic drainage of the stomach corresponding its blood supply.

AnatomyAnatomy

• Stomach has five layers: Mucosa Epithelium, lamina propria, and muscularis

mucosae* Submucosa Smooth muscle layer Subserosa Serosa

Gastric polypsGastric polypsFundic gland polyps most common.

(associated with long use of PPIS)Metaplastic polyp (hyperplastic) .

(associated with H. pylori infection)Inflammatory polyps.Hamartomatus polyps.Familial polyposis syndrome.

Premalignant polypsAdenoma (10% of polypoid lesions.)All G polyps should be BxAll polyps above 1cm should be removed

Gastric polypsGastric polyps

Carcinoma of the stomachEpidemiology

Stomach cancer is the fourth most common cancer worldwide .5% of stomach cancers occur in people less than 40 years . It is a disease with a high death rate (700,000 per year). It is the leading cancer type in Korea.Carcinoma of the distal stomach & body is most common in low socio-economic groups.

Carcinoma of the stomachCarcinoma of the stomach Aetiology• H. pylori is the main risk factor in 65–80% of

gastric cancers. Risk is increased with Autoimmune atrophic gastritis(Achlorhydria). Intestinal metaplasia. Gastric polyps. Smoking increase the risk is nearly twice. Diet : smoked food , salted fish ,meat & pickled

vegetables. Gastric remnants.  Blood group A ,Family history ,race.

PathologyPathologyStomach cancers are overwhelmingly adenocarcinomas (95%).Aggressively invade the gastric wallAround 4% of gastric malignancies are lymphomas.Carcinoids and stromal tumors GIST 1% .Proximal stomach is now the most common site for Ca. in the west.Distal cancer Japan, still predominates, as it does in most of the rest of the world.

Pathology continuePathology continue

Two Lauren Lauren histology types• Intestinal type Diffuse type• M:F 2-1 1-1• Well differentiated Poorly differentiated • Glandular muc origin lamina propria origin• Older people Younger people ,familial• Distal tumors Proximal tumor• 5y survival 20% 10%Diffuse type grow in infiltrative sub mucosal

pattern.

PathologyPathology

Early gastric cancerCancer limited to the mucosa and sub mucosa regardless of lymph node status(T1, any N)Curable, and even early with lymph node involvement .5-year survival rates around 90%.30% of cases in Japan diagnosed early.

PathologyPathology

Advanced gastric

• Cancer involves the muscularis. • Its macroscopic appearances have been

classified by Bormann into four types Types III and IV are commonly incurable.

))Linitis PlasticaLinitis Plastica“ ,(“ ,(leather bottle stomachleather bottle stomach””

))UICCUICC ( (staging of gastric cancerstaging of gastric cancerUnion international cancer controrUnion international cancer contror

T1 Tumor involves lamina propriaT2 Tumor invades muscularis or subserosaT3 Tumor involves serosaT4 Tumor invades adjacent organsN0 No lymph nodesN1 Metastasis in 1–2 regional nodesN2 Metastasis in 3–6 regional nodesN3 Metastasis in more than 7 LNM0 No distant metastasisM1 Distant metastasis ( perit and distant LN)

Staging of gastric carcinomaStaging of gastric carcinoma• Stage IA T1 N0 M0• Stage IB T1 N1M0 , T2 N0 M0• Stage II T1 N2 M0 T2 N1 M0 , T3 N0 M0• Stage IIIA T2 N2 M0 T3 N1 M0, T4 N0 M0• Stage IIIB T3 N2 M0• Stage IV T4 N1–3 M0 T1–3 N3 M0, Any T Any N M1

PathologyPathology Spread of gastric tumors

Direct spread The tumor penetrates the muscularis, serosa adjacent organs such as the pancreas, colon and liver.

Lymphatic spread permeation and emboliBlood-borne metastases first to the liver

Then lungs & bone (usually after LN mets)Transperitoneal spread indicates incurability

Tumor shelf, Krukenberg’s tumors, Sister Joseph’s nodule, Ascites.

Clinical features

Stomach cancer is often asymptomaticMay cause only nonspecific symptoms Early Dyspepsia , heartburn Loss of appetite, especially for meat.Late cases: Upper abdo pain, nausea ,occasional vomiting diarrhea or constipation ,Wt. loss, anemia & dysphagia , jaundice Virchow’s node. Thrombophlebitis .

Trousseau’s syndromeTrousseau’s syndrome(thrombophlebitis(thrombophlebitis))

Acanthosis Acanthosis NigracansNigracans

Prompt Prompt upper endoscopy upper endoscopy ifif ……

New onset of dyspepsia > 45 yearsDyspepsia with alarm symptoms (weight loss, anemia, recurrent vomiting, bleeding).Dyspepsia & family H/o gastric carcinoma.Gold standard for diagnosis.

Preoperative StagingPreoperative Staging

Abdominal / pelvic CT scanning PET CT scan Endoscopic ultrasound (EUS)

Depth of the tumorEnlarged perigastric/coeliac lymph nodes Diagnostic laparoscopy.

TreatmentTreatment

Radical surgery for early disease. (Curative resection )

Palliative surgery for incurable disease Haematogenous metastasisInvolvement of the distant peritoneumN4 nodal disease .Fixation to structures that cannot be removed

TreatmentTreatment Surgical treatmentTotal gastrectomyThe stomach is removed en bloc, including the

tissues of the entire greater omentum and lesser omentum Oesophagojejunostomy is reconstituted by means of a Roux loop (50 cm long)LN dissection : D1 ,D2 ,D3, D45-year survival rate post op. is 25–30%

TreatmentTreatmentSubtotal gastrectomy

Indicated for distal diseaseProximal stomach is preserved.Reconstruction is either by 1. BillrothII-/Pólya-type gastrectomy,

(Entero-gastric reflux and bile reflux esophagitis) OR

Roux loop.No difference in prognosis and 5 y survival for distal tumors between total or subtotal resection

• D1: stations 3-6• D2: stations 1,2, 7,8 and 11• D3: stations 9, 10 and 12

TreatmentTreatmentPalliative surgery

Aim : Relives obstruction or bleedingRemove the tumor Reconstruct the GI tract.May be bypass only OR Intubation, stenting, recanalization.

Adjuvant TreatmentAdjuvant Treatment

RadiotherapyPalliative treatment of painful bony mets.

Chemotherapy• Most patients should have chemotherapy before

surgery (T may respond well)• Regimen: combination of epirubicin, cis-platinum

& infusional5-fluorouracil (5-FU) or an oral analogue such as capecitabine

• Palliative for advanced disease

GASTROINTESTINAL STROMAL GASTROINTESTINAL STROMAL TUMOURS (GISTs)TUMOURS (GISTs)

Common but remain unnoticed, over 70y.Arise from mesenchymal cells ICOCDue to mutation in the tyrosine kinase c-kit oncogene.Noticed incidentally at endoscopy.Mucosa over may ulcerate & bleed.Peritoneal and liver metastases are most common ,LN mets is very rare.Size and mitotic countTreatment : endoscopic removalLarge T surgery Imatinib (tyrosine kinase antagonist.

GASTRIC LYMPHOMAGASTRIC LYMPHOMA Pathology95% are non-Hodgkin’s B lymphoma

Cell-derived, the tumor arising from the mucosa-associated lymphoid tissue (MALT).

Early stage, the disease takes the form of a diffuse mucosal thickening, ? UlcerateRemains in the stomach for a prolonged period before involving the lymph nodes

Diagnosis Endoscopy & Bx , CBC & CT

GASTRIC LYMPHOMAGASTRIC LYMPHOMA

TreatmentSurgery alone for the localized disease Chemotherapy alone is appropriate for patients with systemic disease. Treatment of Diffuse lymphoma Chemotherapy, sometimes with dramatic & rapid responseSurgery for complications bleeding and perforation

Gastric carcinoidGastric carcinoidConstituting less than1% of all carcinoid tumorsLess than 2% of all gastric neoplasmsEqual male & female , Age less than 50 years.Most common presentation is abdo pain , GI bleeding ,flushing ,diarrhea & obstruct. Diagnosis by upper endoscopy with biopsy & extensive sampling .Treatment : varies according to type & size ranging from EMR to , local excision , partial or near total gastrectomy

DUODENAL TUMOURSDUODENAL TUMOURS Benign duodenal tumors

Villous adenomas commonly in the periampullary region.Adenomas uncommon found in patients with familial adenomatous polyposis.Treatment : Local excision with safety margins

DUODENAL TUMOURSDUODENAL TUMOURS Duodenal adenocarcinoma

Most common site for adenocarcinomas arising in the small bowel , GISTs rare.Site : in the periampullary region arising from pre-existing villous adenomas.Clinically: bleeding ,obstruction,? obst jaund.Mets are commonly to regional LN & liver.At presentation, 70% of the patients have resectable diseaseTreatment : Whipple’s procedure5-year survival rate is in the region of 20%.

GASTRINOMA & ZE SYNDROMEGASTRINOMA & ZE SYNDROME

Definition of ZES

(ZES) is a condition that includes fulminating ulcer diathesis in the, duodenum or jejunum, recurrent ulceration despite adequate therapy; and non-beta islet cell tumors (gastrinoma).

Incidence Solitary ulcer less than 1 cm in D1 75% More in malesMay be associated with MEN type I (25%)

Z-E syndromeZ-E syndrome

• Clinical presentationPeptic ulcer 90%Diarrhea 75%Abdo pain, heart burn,GIT bleeding, weight loss.Metastatic disease 33% to liver, bone.

Diagnosis is delayed for 5-6 years.

GastrinomaGastrinoma

Distal DU

GASTRINOMA

GASTRINOMA contGASTRINOMA cont…… Pathology• Gastrinoma triangle (Passaro) : Head of panc ,1st &

2nd part of duodenum 80% of casesTwo types

More in Antral G cell 70%. Pancreatic origin 20% 60% of cases are Malig, slowly growing

Clinically : Mean age is 38 y, Diarrhea is 1st symptoms in 40% steatorhea, Hypokalemia, intractable recurrent PU ,distal DU & JU in 90% of cases

GastrinomaGastrinoma

GASTRINOMA Usually>1cm

Duodenal Gastrinoma Usually <1cm

GASTRINOMA contGASTRINOMA cont……Serum Gastrin is elevated

Treatment Surgery is the only chance for cure if no Mets.Gastrectomy or ExcisionChemotherapy : if ? Mets Streptozotocin in combination with 5-fluorouracil or doxorubicin is the first-line of treatment