GASTRIC Flashcards
Unresectable gastric cancer
N3
or
invasion or encasement of major vessels (excluding splenics )
or
mets
Treatment of unresectable gastrci cancer
chemoXRT
5 fu
consider palliative gastrectomy, gastrojej, or GT/JT
stages of gastric cancer
mucosa = T1a, submucosa = T1b -
muscularis propria = T2 (NEO ADJ)
subserosa = T3,
serosa = T4a, invades adjacent organs = T4b)
Treatment of >= T2 gastric cancer
musulcaris propria
neoadj
D1
Nodes from:
“perigastric”
peripyloirc
greater and lesser omentum
including R and L cardiac,
D1 lymphadenectomy refers to a limited dissection of only the perigastric lymph nodes.
D2
and D3
Now improved survival (uptodate) Dutch study 2015:
A pancreas and spleen-preserving (unless direct extension)
●D2 lymphadenectomy is an extended lymph node dissection, entailing removal of nodes along the
D2 = basically celiac trunc extention..
hepatic a, left gastric a, celiac a, splenic arteries a, as well as those in the splenic hilum --
D3:
D3 dissection is a superextended lymphadenectomy. The term has been used by some to describe a D2 lymphadenectomy plus the removal of nodes within the porta hepatis and periaortic regions (stations 1 to 16), while others use the term to denote a D2 lymphadenectomy plus periaortic nodal dissection (PAND) alone [46]. Most Western surgeons classify disease in these regions as distant metastases and do not routinely remove nodes in these areas during a potentially curative gastrectomy. (uptodate)
there is no evidence that a D3 (paraaortic lymphadenectomy) confers a survival benefit over D2 dissection, and it is associated with greater perioperative mortality. We recommend that a D3 dissection not be considered for surgical treatment of gastric cancer (Grade 1A). (See ‘D2 versus D3 dissection’ above.)
Gastric neo adj chemo
MAGIC trial
5 Fu (because everyone gets 5 Fu)
Cisplatin -
“Stomach is like a big cist - that is platinum plated “
cisplatin
fluorouracil
epirubicin
Three preoperative and three postoperative cycles of
-uptodate
Gastric adjuvant recs
chemoRADIATION
N1 disease (T1N1 stage IB) Same as colon and Melanoma)
T3N0 (stage IIA) - same concept as colon
T2N0 can consider based
disease, either observation or adjuvant treatment is acceptable, and the decision can be based upon individualized patient (such as age, performance status, and motivation for treatment) and disease risk factor (eg, histologic grade or the presence of lymphovascular or perineural invasion) considerations. (See ‘Patient selection’ above.)
gastric nodal staging
N1 Metastasis in 1-2 regional lymph nodes
N2 Metastasis in 3-6 regional lymph nodes
N3 Metastasis in seven or more regional lymph nodes
*N3 NOT RESCTABLE
N3a Metastasis in 7-15 regional lymph nodes
N3b Metastasis in 16 or more regional lymph nodes
early dumping syndrome
liquids vs solids
late dumping
sx:
over shoot insulin - so hypoglycemic symptoms
Treatment:
High-protein
Snacks for symptoms
Medication:
Acarbos
Watermelon stomach
ANTRUM
Dilated vasculature
Can do antrectomy and vagotomy
Describe vagotomy
- Cut the L triangular ligament of liver to retract it out of way
- Expose the esophageal hiatus by incising the peritoneum at the hiatus (be careful of L inferior phrenic vessels here)
- Mobilize the esophagus, encircling it with a Penrose drain
- Anterior vagal trunk taken first, by first mobilizing 2cm of it, the clipping and cutting; excise small portion of the nerve too
- If can’t feel the posterior trunk behind the esophagus, search the posterior tissue between the esophagus and aorta
- Submit the vagal fibers for frozen section confirmation
- Search for any other major fibers and divide these too
- Do pyloroplasty
Confirmation of clearance H. pylori
urea breath test
Treatment of H. pylori
Clarithromycin
Metronidazole
PPI
