Last Minute

Question 1

Gastric cancer work up

Answer 1

Evaluate extent of disease
1. Upper endoscopy
2. PET/CT chest & abdomen/pelvis to assess for mets
3. EUS with FNA to assess for T & N stage
4. Staging laparoscopy w peritoneal washings +feeding tube

Preop risk stratification - Cardiac/EKG, Pulm/PFT’s

Question 2

Siewert Classification of cancer

Answer 2

Upper 1/3 stomach cancer

I: 1-5 cm above anatomic EGJ → esophageal CA
II: 1 cm proximal to 2 cm distal EGJ → esophageal CA
III: 2-5 cm distal to EGJ → stomach CA

Question 3

Gastric cancer management: Early

Answer 3

Goal is R0 resection & ≥16 lymph nodes

Tis, T1 (mucosa) → Gastrectomy with D1/D2 lymphadenectomy.

EMR for low risk features & <2 cm

Question 4

Total gastrectomy

Answer 4

1. Midline laparotomy & exploration
2. Mobilize GEJ & esophagus, taking margin of diaphgragmatic crura (don’t injure replaced L)
3. Omental bursectomy performed (Separate omentum & lesser sac lining from transverse colon)
4. Divide short gastric vessels (don’t injury spleen) skeletonize celiac, splenic, common hepatic arteries, taking their lymph nodes
5. Ligate L & R gastric/gastroepiploic arteries at their base (L gastroepiploic & splenic are preserved during subtotal)
6. Divide esophagus with a TA & duodenum 2 cm distal to pyloric vein with GIA, ensuring 5 cm negative margin. Divide the jejunum 20 cm distal to LOT w GIA.
7. Reconstruction with a roux-en-Y EJ using an EEA stapling device & JJ; Place a jejunostomy feeding tube vs corpak past the anastomosis & drains near duodenal stump & EJ

Question 5

Total gastrectomy post-op management

Answer 5

1. NGT to LIS, start TF’s vs J tube feeds POD#2
2. Send amylase/bilirubin from drains & remove if <3x serum value
3. Contrast swallow study 2 weeks later, then can start PO feeds
4. Need multivitamin, B12, iron for life
5. H&P w routine labs q3-6 months, semiannual CT for 5 years, then annually

Question 6

Ivor-lewis esophagectomy

Answer 6

Laparotomy
1. Mobilize greater curvature of stomach, preserve gastroepiploic arcade
2. Perform Kocher maneuver to allow conduit to reach into chest
3. Complete mobilization of the stomach, preserve R gastric & R gastroepiploic arteries, ligate L gastric artery at origin & perform hiatal dissection, keeping lymphatic tissue with specimen
4. Create gastric conduit, transecting stomach 5 cm distal to tumor, suturing it to the specimen so it can be pulled into chest

Right thoracotomy with Thoracic Surgery
1. R lateral thoracotomy, mobilization of esophagus/lymphatic tissue up to & transected at the azygous vein.
2. Remove specimen, bring gastric conduit up from abdomen
3. Use circular stapler to perform upper thoracic anastomosis
4. Leave 2 chest tubes for drainage & close