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)
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)
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.
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.
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)
Nasogastric aspiration with saline lavage. (Detection intragastric bleeding,type of bleeding- red blood/coffee ground,endoscopic visualization,prevent aspiration of gastric contents.)
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.
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.
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
Closed suction drainage/Jacksonn Patt drain placement. Site : suprahepatic and infrahepatic recesses, the lesser sac, the paracolic gutters, and pelvis.
Crystalloid solutions. The goals of resuscitation focus on urinary output, lactic acid levels, mean arterial pressure, and central venous pressure parameters.
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/
“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
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.