The document discusses gastric cancer surgery, including classifications of resection margins (R0, R1, R2) and lymph node dissection (D1, D2, D3, D4). It describes procedures for different tumor locations like total gastrectomy for proximal or middle tumors versus subtotal gastrectomy for distal tumors. Complications after different reconstruction methods are outlined, and the use of palliative treatments for advanced cancer is covered.

1. DR CHITTIBABU KT

2. R0R1 R2 D1 D2 D3D4
ROUX ENYBILROTH 1
BILROTH 2

3.  Resection Classification
 The R classification system indicates the amount
of residual disease left after tumor resection.
 R0 indicates no gross or microscopic residual
disease;
 R1 indicates microscopic residual disease, and
 R2 signifies gross residual disease.
 Surgeons should wait for the final pathology
results before completing their operative
summaries so that patient records include the R
classification for the gastrectomy.

4.  Dissection classification: D1 D2 D3 D4
 Lymph node stations :
 The Japanese Research Society for Gastric Cancer
has numbered the lymph node stations that
potentially drain the stomach

5. D1 D4D3D2

7.  Roux-en-Y gastrojejunostomy
 Interposition of a 40-cm isoperistaltic jejunal
loop between the gastric remnant and the
duodenum (Henley loop)

8.  Bilroth 1
 The pylorus is removed and the
proximal stomach is anastamosed directly to
the duodenum.

9.  Bilroth 2
 The greater curvature of the stomach is
connected to the first part of the jejunum in
end-to-side anastomosis.
 The Billroth II is often indicated in
 Refractory peptic ulcer disease and
 gastric adenocarcinoma.

11.  OG JUNCTION & PROXIMAL
 MIDDLE
 DISTAL
 EXTENT OF LYMPHADENECTOMY
 RECONSTRUCTION
 PALLIATION

12.  For the best chance at curing a patient from
gastric cancer, surgical resection remains the
first-line therapy.

13.  The goal of curative surgical treatment is
resection of all tumor (i.e., R0 resection).
 Thus, all margins (proximal, distal, and radial)
should be negative and an adequate
lymphadenectomy performed.

14.  Generally, the surgeon strives for a grossly
negative margin of at least 5 cm.
 Some gastric tumors, particularly the diffuse
variety, are quite infiltrative and tumor cells
can extend well beyond the tumor mass;
thus, gross margins beyond 5 cm may be
desirable.

15.  Classification of Esophagogastric Junction
Cancers
 Siewert and Stein classification system for
adenocarcinoma of the esophagogastric
junction

16.  Type 1: Adenocarcinoma of the distal esophagus,
which usually arises from an area with specialized
intestinal metaplasia of the esophagus (i.e., Barrett's
esophagus) and may infiltrate the esophagogastric
junction from above;
 Type II: Adenocarcinoma of the cardia, which arises
from the epithelium of the cardia or from short
segments with intestinal metaplasia at the
esophagogastric junction;
 Type III: Adenocarcinoma of the subcardial stomach,
which may infiltrate the esophagogastric junction or
distal esophagus from below.

17.  These are most often treated with an
 Ivor-Lewis esophagogastrectomy or
 esophagectomy with gastric pull-up procedure
via the transhiatal approach.

18.  Surgeons trained in thoracic surgery have
frequently advocated
 a combined abdominal and thoracic procedure (often
termed esophagogastrectomy) with an intrathoracic
or cervical anastomosis between the proximal
esophagus and the distal stomach or
 a procedure termed transhiatal (or blunt)
esophagectomy (THE), which involves resection of
the esophagus and esophagogastric junction with
mediastinal dissection performed in a blunt fashion
through the esophageal hiatus of the diaphragm.

19.  These two types of gastric carcinomas most
often result in resection via a
 total gastrectomy.

20.  Most tumors occurring in the midbody of the
stomach require a total gastrectomy for
curative resection owing to the need for
negative margins.

21.  Although proximal tumors may require a
total gastrectomy for adequate negative
margins, distal tumors often only need a
subtotal gastrectomy for surgical resection
to be successful

22.  Endoscopic Mucosal Resection
 Limited Surgical Resection
 Gastrectomy

23. SITE PROCEDURE
OG JUNCTION Ivor Lewis Esophagogastrectomy or
transhiatal esophagectomy (THE)
PROXIMAL Total Gastrectomy
MIDDLE Total Gastrectomy
DISTAL Distal Gastrectomy
RECONSTRUCTION +

24.  The extent of lymph node involvement is related
to the stage of the primary tumor, with tumor
located in the
 mucosa having only a 5% chance of lymphatic
spread.
 If the tumor has reached the submucosa, the
 involvement of lymph nodes can be as high as 25%.
 Higher percentages of nodal involvement,
 greater than 90%, are associated with stage III and
IV tumors.

25.  The standard operation is the D2
gastrectomy, which involves a more
extensive lymphadenectomy (removal of the
D1 and D2 nodes).


26.  In terms of survival the meta analysis shows
no statistically significant difference between
D1 & D2 groups- weighed 5Yr SR was
 45% for D2 &
 47% for D1.

27.  Overall, the D2 resections not involving
pancreaticosplenectomy were found to be
the most advantageous.

28.  Surgeon preference is perhaps the most
important factor in determining the
procedure for reconstruction after distal
gastrectomy.

29.  After Subtotal Gastrectomy
 Billroth I gastroduodenostomy,
 Billroth II gastrojejunostomy, and
 Roux-en-Y gastrojejunostomy.
 AfterTotal Gastrectomy
 Roux-en-Y esophagojejunostomy,
 Jejunal interposition
 Pouch reconstruction.

30.  Billroth I gastroduodenostomy,
 We do not generally recommend a Billroth I
gastroduodenostomy for malignant disease
resections.

31.  Billroth II gastrojejunostomy
 Billroth II can be employed if the resection of the
distal stomach leaves a large enough gastric
remnant.

32.  Roux-en-Y gastrojejunostomy.
 Roux-en-Y gastrojejunostomy has become a
popular choice owing to the ability to use a
smaller gastric remnant with
▪ better bile reflux control and
▪ less postoperative dumping syndrome observed.

33.  Jejunal pouch
 A jejunal pouch can be fashioned, in much the
same manner as an ileal J pouch, enabling a
neostomach to be created when a total
gastrectomy is performed.

34.  A variety of disorders may occur after gastric
resection that are greatly influenced by the
type of reconstruction performed to
reestablishGI continuity.
 By far, the majority of problems develop in
patients who have previously undergone a
Billroth II gastrectomy.

35.  BILE REFLUX GASTRITIS
 AFFERENT AND EFFERENT LOOP
OBSTRUCTION
 JEJUNOGASTRIC INTUSSUSCEPTION
 THE ROUX SYNDROME

36.  BILE REFLUX GASTRITIS
 Bile reflux commonly occurs after gastric surgery
regardless of the procedure performed.
 Bile in the stomach on endoscopic examination is
often seen when the pyloric sphincter has been
ablated or resected;
 it is even more commonly encountered if a
portion of the distal part of the stomach has been
resected, regardless of whether a Billroth I or
Billroth II reconstruction has been fashioned.

37.  BILE REFLUX GASTRITIS
 In a small subset of patients such reflux is
associated with
▪ marked, unrelenting epigastric pain,
▪ nausea,
▪ bilious vomiting, and
▪ quantitative evidence of excessive enterogastric reflux.

38.  BILE REFLUX GASTRITIS
 Medical treatment, including
 acid secretory inhibitors,
 anticholinergic drugs, and
 cholestyramine
 Patients with unrelenting or intractable
symptoms can be managed with surgery.

39.  BILE REFLUX GASTRITIS
 These procedures include conversion to a
 Roux-en-Y gastrojejunostomy

40.  BILE REFLUX GASTRITIS
 AFFERENT AND EFFERENT LOOP
OBSTRUCTION
 JEJUNOGASTRIC INTUSSUSCEPTION
 THE ROUX SYNDROME

41.  BILE REFLUX GASTRITIS
 AFFERENT AND EFFERENT LOOP
OBSTRUCTION
 JEJUNOGASTRIC INTUSSUSCEPTION
 THE ROUX SYNDROME

42.  AFFERENT AND EFFERENT LOOP
OBSTRUCTION
 Afferent loop obstruction, known as the
afferent loop syndrome, is a mechanical
problem resulting from the inability of this
loop to empty its contents.

43.  AFFERENT AND EFFERENT LOOP
OBSTRUCTION

45.  THE ROUX SYNDROME
 Occasionally, a patient who has undergone
distal gastrectomy with a Roux-en-Y
reconstruction will have difficulty with gastric
emptying along with the symptoms of
 gastric vomiting,
 epigastric pain, and
 weight loss.

46.  THE ROUX SYNDROME
 Endoscopically, the gastric remnant may be
dilated, as well as the Roux limb, but no
evidence of mechanical obstruction can be
identified on CT or upper GI series.
 The only significant finding with this latter study
is a delay in gastric emptying.
 This constellation of clinical findings has been
called the Roux syndrome or the Roux stasis
 syndrome.

47.  THE ROUX SYNDROME
 The cause of this syndrome appears to be an
abnormality in motility.
 This disordered motility appears to occur in
all patients after this procedure, but why the
Roux syndrome develops in only a small
subset remains unknown.

48.  THE ROUX SYNDROME
 Endoscopically, the gastric remnant may be
dilated, as well as the Roux limb, but no
evidence of mechanical obstruction can be
identified on CT or upper GI series.
 The only significant finding with this latter study
is a delay in gastric emptying.
 This constellation of clinical findings has been
called the Roux syndrome or the Roux stasis
 syndrome.

49.  PalliativeChemotherapy
 Palliative Surgery
 Palliative Radiotherapy
 Half of patients diagnosed with gastric
adenocarcinoma are in need of palliation
rather than curative resection at the time of
presentation.

50.  For patients with advanced cancer, the two most
commonly used surgical techniques for
palliation are
 Resection and
 Bypass
 Although resection may offer a greater chance
at disease-free survival, the specific
circumstances of each patient may dictate the
need for bypass.

51.  However, some patients may be unable to
tolerate, both anatomically and physically, a
resection and the need for a gastrojejunal
bypass procedure could be required.

52.  If performance status is acceptable, palliative
chemotherapy can be used to help patients
with advanced disease.
 Multiagent regimens, much the same as
those used for nonpalliative patients, can be
used.
 Survival can be improved by up to 6 months
with the use of chemotherapy when
compared to supportive measures.

53.  Unfortunately, because of the presence of
node-positive disease, radiotherapy has a
limited role in the palliative setting..

54.  Current trials are under way to evaluate the
long-term outcomes of using neoadjuvant
chemoradiation in the setting of gastric
adenocarcinoma.