Cancer stomach or Gastric cancer incidence is increasing nowadays. For more details , plz visit https://drnitinjha.com/

1. drnitinjha@yahoo.com

2. GASTRIC CANCER SURGERY
Dr Nitin Jha
(MBBS,MS,FIAGES)
Consultant
Laparoscopic,MIS and Bariatric surgeon
FORTIS Hospital, Noida. INDIA
drnitinjha@yahoo.com
drnitinjha@yahoo.com

3. GASTRIC CANCER
 Leading cause of death worldwide
 Adenocarcinoma
 Incidence of SCC increasing in fundus region
 Early detection and management leads to best
prognosis
drnitinjha@yahoo.com

4. ANATOMY

5. BLOOD SUPPLY :

6.  LYMPHATIC DRAINAGE :

8. Gastric Cancer Etiology
• Pernicious anaemia
• H-PYLORI INFECTION
• Blood group A
• Family history of gastric cancer
 Deletion or suppression of p53
 Overexpression of COX-2
• High fat diet
• Pickled, preserved food
• Tobacco
• Regular aspirin

9. Gastric Cancer
Pre-malignant Conditions
 Polyps
 Atrophic gastritis
 Benign gastric ulcer
 Gastric ramnant

10. STOMACH TUMORS
Benign
 Polyps
 Hyperplastic
 Fundic gland
 Neoplastic
 Multiple
 Tumors
 Leiomyomas
 Lipomas
 Heterotopic pancreas
Malignant
 Tumors
 Adenocarcinoma
 Lymphoma
 Sarcoma
 Carcinoid
Others
 Menetriers Disease
 Bezoar
 Volvulus

11. H.Pylori infection
Superficial gastritis
Atrophic gastritis
Intestinal metaplasia
Dysplasia
Cancer

12. 1. Polypoidor Proliferative
2. Ulcerating
3. Ulcerating/Infiltrating
4. DiffuseInfiltrating(Linnitus-
Plastica)
(Bormann classification) MACROSCOPIC

13. LAUREN CLASSIFICATION ON
MICROSCOPY
 Diffuse
 M:F 1:1
 Onset Middle Age
 5 yr surv overall <10%
 Aetiology
 Diet
 H. pylori
 Intestinal
 M:F 2:1
 Onset Middle Age
 5 yr surv overall 20%
 Aetiology
 Unknown
 Blood group A association
 H. pylori

14. SPREAD OF GASTRIC CANCER:
Thespreadby:
1. Direct (loco regional)
2. Lymphatic
3. Blood (Haematogenous)
4. Transcoelomic

15. T STAGING:

16. Gastric Cancer
TNM staging
N0 No regional lymph node metastases
N1 Metastasis in 1 to 6 regional lymph nodes
N2 Metastasis in 7 to 15 regional lymph nodes
N3 Metastasis in more than 15 regional lymph
nodes

17. Gastric Cancer
TNM staging
M0 No distant metastasis
M1 Distant metastasis

18. STAGING OF GASTRIC CANCER:
a. TNM System
b. CT Staging
c. PHNS Staging System (Japanese)
 P-factor (Peritoneal dissemination)
 H-factor (Thepresenceofhepatic metastases)
 N-factor (Lymphnodes involvement)
 S-factor (Serosal invasion)

19. Clinical Manifestation:
1. Weight loss due to anorexia and early satiety is the
most common symptoms
2. Abdominal pain (not severe) common
3. Nausea / vomiting
4. Chronic occult blood loss is common;
GIT bleeding (5%)
5. Dysphagia (cardia involvement)

20. Clinical Manifestation:
6. Paraneoplastic syndromes ( Trousseau’s syndrome –
thrombophlebitis; acanthosis nigricans –
hyperpigmentation of axilla and groin; peripheral
neuropathy)
7. Signs of distant metastasis:
a. Hepatomegally / ascites
b. Krukenbergs tumor
c. Blummers shelf (drop metastasis)
d. Virchow’s node
e. Sister Joseph node (pathognomonic of
advances dse)

23. Clinical Signs
 Cervical, supraclavicular and axillary
lymphadenopathy
 Pleural effusion
 Aspiration pneumonitis
 Abdominal mass
 Sister Joseph’s nodule
 Ascites
 Rectal shelf of Blumer

25. Gastric Cancer
INVESTIGATIONS :

26. upper endoscopy + Biopsy
 New onset of dyspepsia >45 years
 Dyspepsia with alarm symptoms (weight
loss, anaemia, recurrent vomiting,
bleeding)
 Dyspepsia & family h/o gastric carcinoma

27. Preoperative Staging
 USG Abdomen
 Abdominal / pelvic CT scanning
 Whole body Positron Emission Tomography scanning
(PET):
 Tumor cell preferentially accumulate positron-emitting 18F
fluorodeoxyglucose
 Endoscopic ultrasound (EUS)
 Depth of the tumour
 Enlarged perigastric/coeliac lymph nodes

29. Laparoscopy
 Inspect peritoneal surfaces, liver surface.
 Identification of advanced disease avoids non-
therapeutic laparotomy in 25%.
 Patients with small volume metastases in peritoneum
or liver have a life expectancy of 3-9 months, thus
rarely benefit from palliative resection.

30. Screening of Gastric Cancer
 Patients at risk for gastric CA should undergo
yearly endoscopy and biopsy:
1. Familial adenomatous polyposis
2. Hereditary nonpolyposis colorectal cancer
3. Gastric adenomas
4. Menetrier’s disease
5. Intestinal metaplasia or dysplasia
6. Remote gastrectomy or gastrojejunostomy

31. Gastric Cancer
MANAGEMENT :

32. Endoscopic Resection of Gastric
Carcinoma
Criteria:
1. Tumor < 2cm in size
2. Node negative
3. Tumor confined on the mucosa
Nodes metastasis is < 1%:
1. No mucosal ulceration
2. No lymphatic invasions
3. <3cm tumor

33. Surgical Resection
 Resection of tumour
 Grossly negative margin of at least 5 cms
 Distal or Total gastrectomy
 Confirmed on frozen section
 En block resection of adjacent involved organs

34. TREATMENT:
SURGERY:
 The only curative tx for gastric cancer
 Except:
1. Can’t tolerate abdominal surgery
2. Overwhelming metastasis
 Palliation is poor w/ non-resective operations
 GOAL: resect all tumors, w/ negative margins (5cm)
and adequate lymphadenectomy (need for RFS)
 Enbloc resection of adjacent organ is done if
needed.

35. TREATMENT:
SURGERY:
Radical subtotal
gastrectomy
 Standard operation for
gastric cancer
Organs resected:
1. Distal 75% of stomach
2. 2 cm of duodenum
3. Greater & lesser omentum
4. Ligation of R & L gastric
artery and gastroepiploic
vesels
5. Billroth II
gastojejunostomy

36. TREATMENT:
SURGERY:
Radical total gastrectomy
 Standard operation for
gastric cancer
If gastric remnant left is small
(<20%) do Roux-en-Y
reconstruction

37. LYMPHADENECTOMY
D1: stations 3-6
D2: stations 1,2, 7,8 and 11
D3: stations 9, 10 and 12

38. Treatment of gastric cancer
 Endoscopic treatment
 EMR (endoscopic mucosal resection)
 ablation
 Surgery
 Multimodal treatment
 Neo-adjuvant
 Adjuvant
 Palliative treatment

39. Advanced Unresectable Disease
 Surgery is for palliation, pain, allowing oral intake
 Radiation provides relief from bleeding, obstruction
and pain in 50-75%. Median duration of palliation is 4-
18 months

40. Outcome
 5-year survival for a curative resection is 30-50% for
stage II disease, 10-25% for stage III disease.
 Adjuvant therapy because of high incidence of local
and systemic failure.
 A recent Intergroup 0116 randomized study offers
evidence of a survival benefit associated with
postoperative chemoradiotherapy

41. Complications
 Mortality 1-2%
 Anastamotic leak, bleeding, ileus, transit failure,
cholecystitis, pancreatitis, pulmonary infections, and
thromboembolism.
 Late complications include dumping syndrome,
vitamin B-12 deficiency, reflux esophagitis,
osteoporosis.

42. VIDEO
Lap D2
Gastrectomy !
drnitinjha@yahoo.com

43. THANKS !
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