Oncological Emergency : Gastric Cancer

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Oncological Emergency : Gastric Cancer

  1. 1.  Abdominal (Gastric Cancer) - Ahmad Abid Solid organ (HCC) – Ahmad Ashraf Upper extremities – Ahmad Danial Lower extremities – Ahmad Farabi Head and Neck- Adiba & Adibah General – Khaireza (state of consciousness and hemorrhage)
  2. 2. Ahmad Abid Bin Abas 07-6-2
  3. 3. More prominent in case of advanced gastric cancer. Early satiety,bloating,distension and vomiting may occur. If tumour bleeds will lead to iron def. anemia. Obstruction will lead to dysphagia,epigastric fullness or vomiting. With pyloric involvement will lead to gastric outlet obst. Metastatic LN may be palpable (Virchow’s Nodes)
  4. 4.  Medical Hx/Phys. Exam (Signs and symptoms) Lab tests – CBC, LFT,RFT,Carcinoembryonic Ag. and CA19.9 EGD and Biopsy,EUS guided biopsy,CT guided needle biopsy. Imaging – Barium Swallow,CT Scan,MRI,CXR for metastatic lesion.
  5. 5.  Surgery,Chemotherapy,Radiation,LN Removal D1,D2.
  6. 6.  Emergency surgery within 24h of presentation for gastric malignancy is extremely rare. Presentation :1. Haematemesis2. Visceral perforation3. Gastric Outlet Obstruction PE : Severe abdomen tenderness suggests GI bleeding assoc. with GI Obst,GI perforation and bowel ischemia.
  7. 7.  Two-staged procedural approach.1. First stage – Control the perforation,bleeding and obstruction. (Emergency lifesaving intervention)2. Second stage – Definitive gastrectomy with LN dissection after histological confirmation and accurate staging. (Emergency cancer therapy)
  8. 8.  Nasogastric aspiration with saline lavage. (Detection intragastric bleeding,type of bleeding- red blood/coffee ground,endoscopic visualization,prevent aspiration of gastric contents.)
  9. 9.  General Measure : (fluid replacement,blood transfusion,care of abdomen from further trauma,cardiorespiratory support,Rx comorbid disease like sepsis,coronary artery disease.) *EGD should be delayed until patient is adequately resuscitated and stabilized.
  10. 10.  Specific measures : EGD (procedure of choice,diagnostic and therapeutic tool for UGIB)1. Injection therapy (adrenaline)2. Ablative therapy (electrocautery,argon plasma coagulation)3. Mechanical therapy (endoclips or banding) May require surgery for bleeding control if endoscopic measures for hemostasis fail.
  11. 11. 1. Endoscopic stentinghttp://www.hopkins-gi.org/GDL_Disease.aspx?CurrentUDV=31&GDL_Cat_ID=AF793A59-B736-42CB-9E1F- E79D2B9FC358&GDL_Disease_ID=DB2F8EAC-4421-41DD-B04E-684AFEF2AD94
  12. 12.  (Surgical) :1. Surgical bypass with gastrojejunostomy.2. Palliative distal gastrectomy.
  13. 13.  Exploratory laparotomy and application of Omental patch (Graham patch) Peritoneal washout - peritoneal cavity is to be irrigated with 10 liters of warm saline solution to remove further contamination.http://www.saudijgastro.com/article.asp?issn=1319- 3767;year=2011;volume=17;issue=2;spage=124;epage=128;aulast=Maghsoudi
  14. 14.  Closed suction drainage/Jacksonn Patt drain placement. Site : suprahepatic and infrahepatic recesses, the lesser sac, the paracolic gutters, and pelvis.
  15. 15.  Crystalloid solutions. The goals of resuscitation focus on urinary output, lactic acid levels, mean arterial pressure, and central venous pressure parameters.
  16. 16.  Jejunostomy feeding tube. http://www.uofmmedicalcenter.org/healthlibrary/Article/86497
  17. 17.  Oral feeding is likely to be delayed. Intraoperative placement of a jejunostomy feeding tube may be benefit the patient. Alternative : Intraoperative or postoperative placement of a double lumen gastro-jejunal tube. Catheters - Parenteral nutrition sometimes used. *Generally, enteral nutrition distal to the perforation would be preferable if possible. http://emedicine.medscape.com/article/1892935-overview#aw2aab6b5 http://patients.gi.org/topics/enteral-and-parenteral-nutrition/
  18. 18.  “Antimicrobial therapy should be continued postoperatively for 24 hours when the perforation has been surgically closed in the first 12 hours” - Infectious Guidelines of the Disease Society of America and Surgical Infection Society Goals : Normalization of WBC counts and temperature after 24h postoperatively. If does not occur,antimicrobials can be continued for 4-7 days. Preferred agents include a beta-lactam/beta-lactamase inhibitor combination or a carbapenem. H pylori eradication should also be considered.http://emedicine.medscape.com/article/1892935-overview#aw2aab6b5
  19. 19.  Following patient recovery and histological confirmation of malignancy, accurate disease staging can be completed, and a radical oncological operation for gastric cancer or neoadjuvant chemotherapy can be planned as appropriately.

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