Download MBBS Surgery Presentations 12 Carcinoma Stomach Lecture Notes

Download MBBS (Bachelor of Medicine, Bachelor of Surgery) 1st Year, 2nd Year, 3rd Year and Final year Surgery 12 Carcinoma Stomach PPT-Powerpoint Presentations and lecture notes


Carcinoma Stomach

Liver tumours

Portal hypertension

Chronic liver disease

Carcinoma Stomach
Introduction

? Gastric cancer is endemic in Japan
? Late stage at diagnosis because of

? Low incidence

? Non specific symptoms

? Risk factors not definable

? Biological y more aggressive
? Increasing incidence of adenocarcinomas of proximal

stomach and distal esophagus

Etiology

? Low acid production

Body of stomach

? H pylori infection

? Low acid production

Esophagus & Cardia

? Reflux
? Obesity
? High BMI
? High glycaemic load diet
? GERD
? Smoking
? Alcohol
? Tobacco

Although no normal lymphoid tissue is found in the

gastric mucosa, the stomach is the most common site

for lymphomas of the gastrointestinal tract


Borrmann classification(depending on

macroscopic appearance)

? Type I: polypoid or fungating cancers
? Type II: ulcerating lesions surrounded by elevated

borders

? Type II : ulcerated lesions infiltrating the gastric wall
? Type IV: diffusely infiltrating tumors
? Type V: unclassifiable cancers
Patterns of Spread

? Local extension
? Lymphatic metastases

? left supraclavicular fossa (Virchow's node)
? left axil a (Irish's node)
? S/c periumbilical tumour deposits (Sister Mary Joseph's nodes)

? Peritoneal metastases
? Distant metastases

Clinical Presentation

? Weight Loss
? Anorexia
? Early satiety (Diffusely infiltrative type)
? Recurrent Vomiting (pyloric involvement )
? Dysphagia
? Bleeding
? Anemia
? Fatigue
? Epigastric pain
? Ascites, jaundice, or palpable mass indicates incurable

disease

? Transverse colon is a potential site of malignant

fistulization and obstruction from gastric primary tumor

? Diffuse peritoneal spread of disease frequently produces

other sites of intestinal obstruction

? Large ovarian mass ( krukenberg's tumor)

? Large peritoneal implant in the pelvis ( blumer's shelf)

? Macroscopic description of the tumor

? Extent of peritoneal metastases (P0-1)

? Extent of hepatic metastases (H0-1)

? Peritoneal cytology findings
Resection Classification

? R0: no gross or microscopic residual disease

? R1: microscopic residual disease (+ margins)

? R2: gross residual disease

Diagnostic work up

? Tumour Markers: CA 19.9,CA 72.4, CEA, CA 50
? Endoscopy & Biopsy:

? Chromo endoscopy: identification of mucosal abnormalities

through topical stains.

? Magnification Endoscopy: magnify standard endoscopic

fields by 1.5- to 150-fold.

? Narrow band imaging: increased visualization of the

microvasculature

? Confocal laser Endomicroscopy : 3D microscopy including

subsurface structures
? Overexpression or amplification of HER2 (EGFR2):

? occurs in approximately 20% of patients with

gastric cancer

? Recommended in metastatic, recurrent gastric

cancer

? Trastuzumab used in Her 2 neu + cancers

? Endoscopic ultrasound (EUS)
? Computed Tomography
? Magnetic Resonance Imaging:

? to characterize liver lesions on CT scan

? Positron Emission Tomography:

? 50% of primary tumors are FDG-negative
? diffuse (signet cel ) subtype most likely to be non-FDG

avid
? Staging Laparoscopy and Peritoneal Cytology:

? directly inspects the peritoneal and visceral surfaces

? done to spare nontherapeutic operations

Treatment

? Surgery (Gastrectomy with lymph node

dissection) `

? Radical Gastrectomy (Proximal gastric cancer)

? Subtotal Gastrectomy (mid & distal gastric cancer)

When the oncologic goal of an R0 resection can be achieved by a gastric-

preserving approach, partial gastrectomy is preferred over total
gastrectomy


A: Subtotal gastrectomy with a Bil roth II anastomosis

B: Total gastrectomy with a Roux-en-Y anastomosis

? Lymphadenectomy

? 15 nodes for adequate pathologic staging



? Partial Pancreatectomy and Splenectomy--Resect or

Preserve?

Splenectomy:

? Intraoperative evidence of direct tumor extension into the

spleen

? Primary tumor is located in the proximal stomach along

the greater curvature

Partial Pancreatectomy:

? direct tumor extension into the pancreas


Stage specific Survival rates for gastric adenocarcinoma are

higher in Japan than in Western countries because:

? Better-prognosis intestinal-type tumors are more common

? Poorer-prognosis proximal gastric cancers are less frequent

? Widespread use of extensive D2 or D3 lymphadenectomy



Chemotherapy

? Adjuvant

? Neoadjuvant:

? Higher rate of R0 resections
? Early treatment of micro metastatic disease

? Periperative
Adjuvant Intraperitoneal Chemotherapy

? Hyperthermic intraoperative peritoneal chemotherapy

(HIPEC)

? Normothermic intraoperative chemotherapy (NI C)

? Early postoperative intraperitoneal chemotherapy (EPIC)

? Delayed postoperative intraperitoneal chemotherapy (DPIC)

Chemotherapy Drugs

? Cisplatin
? 5-Fluorouracil
? Taxanes
? Epirubicin
? Irinotecan
? Trastuzumab (targeted therapy in Her 2 neu + )
Radiotherapy

? Preoperative

? Intraoperative

? Postoperative

Liver Tumours
Benign tumours

? Liver Cell Adenoma

? Focal Nodular hyperplasia

? Hemangioma

? Mesenchymal hamartomas

Liver Cell Adenoma

? benign proliferation of hepatocytes
? young women (aged 20-40 years)
? associated with use of oral contraceptive pills (OCPs)
? usually singular
? Upper abdominal pain
? tumor markers are normal
? MRI scans of LCA have specific imaging characteristics
? two major risks are rupture & malignant transformation
? Hepatic artery embolization
? Resection of the mass
Focal nodular hyperplasia
? Second most common benign tumor
? young women
? small (<5 cm) nodular mass
? involves the right and left liver equally
? Related to developmental vascular malformation
? Nonspecific symptoms
? Contrast-enhanced CT and MRI scan
? Symptomatic pts: resection

Hemangioma
? Most common benign tumor of the liver
? Women more common than men (3:1 ratio)
? Mean age of about 45 years
? Occur equally in the right and left liver
? Usually single
? Lesions > 5 cm are arbitrarily called giant hemangiomas
? Tumor markers are usually normal
? CT and MRI scan
? Resection: enucleation with inflow control
Hepatocel ular carcinoma

Introduction

? Fifth most common malignancy worldwide

? Male-to-female ratio 2.4:1

? Poor prognosis
Etiology

? Infections with hepatitis B and C viruses
? Ethanol abuse
? Obesity
? Type 2 diabetes
? Non-alcoholic fatty liver disease
? Aflatoxin B1

Pathology

? Malignant epithelial neoplasms: 85% to 95%

? Benign: 6 %to 12%

? Malignant mesenchymal tumors: 1% to 3%

? Metastatic tumors
? Tumors metastatic to the liver are:

? Peripheral
? Multiple
? Cause umbilication of surface of the liver

? Primary liver tumors are:

? Central
? Solitary
? Exophytic

? HCC spreads most commonly to

? Lymph nodes around the liver
? Peritoneal cavity
? Lung

Characteristic feature of HCC is invasion of the

portal vein
Clinical Features

Symptoms

Signs

? Abdominal pain

? Hepatomegaly

? Weight loss

? Hepatic bruit
? Ascites

? Weakness

? Splenomegaly

? Ful ness

? Jaundice

? Anorexia

? Wasting

? Abdominal swel ing

? Fever

? Jaundice

? Virchow-Troisier nodes

? Vomiting

? Cutaneous metastases (red-blue nodules)

Paraneoplastic Syndromes

? Hypoglycemia
? Erythrocytosis
? Hypercalcemia
? Hypercholesterolemia
? Dysfibrinogenemia
? Carcinoid syndrome
? Increased thyroxin-binding globulin
? Sexual changes (gynecomastia, testicular atrophy, and

precocious puberty)

? Porphyria cutanea tarda


Diagnostic work up

? Liver function tests
? S. Alpha feto protein (70%)
? S.Des--carboxy prothrombin protein (80%)
? Four-phase CT scan: unenhanced, arterial, venous, and delayed

phases

? MR imaging

Characteristic feature of HCC: rapid enhancement during the

arterial phase of contrast administration and "washout" during

the later portal venous and delayed phases

Portal venous phase of triphasic computed tomography scan


? PET CT Scan: not recommended

? Core biopsy: hal mark feature of HCC is stromal invasion

CHILD PUGH score for assessment of hepatic reserve
Quantitative assessment of hepatic

reserve

Indocyanine green clearance test

? Retention rate <10%: all resections are possible
? 10% to 20%: bisegmentectomy is well tolerated
? 20% to 29%: single segment can be excised
? 30% or more: risk of liver failure is high

Management

Stage I and II HCC
? Surgical resection
? Local ablation (radiofrequency ablation)
? Local injection therapies (ethanol injection):

? maximum size of tumor reliably treated is 3 cm

? Transplantation
Child-Pugh A: Resection
Child-Pugh B and C patients with stage I HCC tumors : transplant, if
appropriate
Adjuvant Therapy

? Trans arterial chemotherapy (TACE)
? Systemic chemotherapy

? Lipiodol
? Doxorubicin
? Mitomycin
? Cisplatin

Stage II and IV Tumors
? TACE

? Regional Chemotherapy

? Systemic Therapy

? External Radiotherapy (< 8 cm)

? Hepatic Arterial Radioisotopes

? yttrium-90 (90Y)
? 131 I antiferritin


Portal Hypertension

Anatomy
? The normal portal pressure is 5-7 mmHg (8-12

cm of water).

? Portal hypertension is present when the portal

vein pressure exceeds 12 mmHg

Causes

? Presinusoidal

? Sinusoidal

? Postsinusoidal


Sequelae & Clinical picture

? Porto-systemic collaterals

? Splenomegaly

? Congestion of the whole GIT

? Bleeding varices

? Ascites




Intra-abdominal venous flow pathways leading to engorged veins

(varices) from portal hypertension

Screening Tests for Portal Hypertension


? Ultrasound with doppler blood flow assessment.

? MRI venogram

? Contrast-enhanced helical CT scan


Detection of oesophageal varices


Management

? Management of patients with actively bleeding

oesophageal varices

? Resuscitation
? Correct coagulopathy
? Prevent encephalopathy
? Sclerotherapy
? Endoscopic Banding
? Drugs: Vasopressin,Somatostatin
? Balloon tamponade

? Trans-juguJar Intra-hepatic Porto-Systemic Shunt
(TIPSS )
? Shunt operations

? Portocaval shunt
? Proximal spleno-renal shunt
? Mesocaval (Drapanas) shunt
? Selective shunt (Warren shunt)

? Liver Transplant

Chronic Liver

Disease






Catabolism of hormones

Glucose homeostasis;

and other serum proteins

glycogenolysis & gluconeogenesis

Chronic Liver

Disease

Synthesis:

- Albumin

- Coagulation factors

Storage:

Bile excretion

- Glycogen

- Iron

- Cu, Iron, vitamins

Signs of CLD

Chronic Liver

Disease


Investigations

Bedside
? Observations, BM, fluid balance, weight
Blood tests
? LFTs (pre/post) (including albumin), INR
? FBC, U&Es, CRP
? Liver screen: autoantibodies, alpha-1 antitrypsin, caeruloplasmin,

serum copper, ferritin, viral hepatitis serology

Imaging
? US abdomen + portal vein doppler
? CXR, CT, MRI, MRCP
Special tests
? Ascitic tap, OGD (oesophageal varices), liver biopsy

What is your management plan?

Conservative
? Alcohol abstinence, optimise nutrition, low salt diet, fluid restriction
Medical
? Vitamin B supplementation (IV/PO), chlordiazepoxide
? Diuretics
? Paracentesis (give albumin)
? NG feeding
? Antibiotics (? SBP)
? Steroids + albumin (N.B. avoid NaCl)
? Lactulose (in hepatic encephalopathy)
Surgical
? TIPSS
? Liver transplantation


Complications of CLD

? Portal hypertension: oesophageal varices, ascites
? SBP
? Hepatic encephalopathy (constipation, GI bleed, infection, renal

failure)

? Hepatocel ular carcinoma
? Coagulopathy
? Hepato-renal syndrome
? Liver failure

? 5 year survival rate in cirrhotic CLD 50%
? Child Pugh Score: bilirubin, INR, albumin, ascites, hepatic

encephalopathy

This post was last modified on 08 April 2022