This document presents two case studies of patients with gastric cancer. The first case is a 60-year-old male who presented with epigastric pain and vomiting for two months. Various tests were performed and it was determined that he had a signet ring cell type adenocarcinoma of the stomach. He underwent a laparoscopic gastrectomy. The second case is a 72-year-old male who also presented with epigastric pain and chest heaviness. He was found to have adenocarcinoma of the stomach as well and underwent a laparoscopic gastrectomy. The document then provides further details on the anatomy, histopathology, classification, staging, signs and symptoms, and management of

1. 1:CASE PRESENTATION
• DR NOSHI KHAN
• PG T SURGERY DEPTT

2. Name : MR . X Y Z
Age: 60yrs, male
Religion: Islam
Marital
status: Married
Profession : Helper in CDA hospital
Address: Barakoh Islamabad
DOA: 28-07-2015 at 12 PM
BIO DATA

3. PRESENTING COMPLAINTS
Epigastric pain 2 months
Vomiting 1 month

4. HISTORY OF PRESENT ILLNESS
 My patient was living a healthy life 2 months back, when he developed
Epigastric pain, it was
 gradual in onset ,
 localized
 non radiating ,
 intermittent burning in character,
 mild in severity, constant between meals, periodically lasting 7-14 days.
 aggravated by food (spicy) and
 relieved by walking and intake of milk and juices.
 associated with bloating weight loss and vomiting
 There is also h/o Weight loss, though not documented, but patient says
that his clothes became lose in last 2 months.
 no relation of posture with pain.
Cont’d…
No h/o of haemetmesis, melena, heart
burn, large bulky greasy stools and altered
bowel habits.
He consulted a local doctor, who gave
him PPIs with which he only got
temporary relief.

5.  After 4 weeks he also developed intractable Vomiting
 occurs after having 2-3 meals,
frequency 1 episode /day usually in the morning. (2-3 times in
each go till the vomitus becomes watery).
projectile in nature,
containing mostly semi digested food particals,
yellowish in colour with offensive acidic smell,
associated with epigastric pain.
Aggravated by intake of meal and relieved by limatation of meal.
no associated complain of hemetemasis ,RHC pain with or without
jaundice, polyuria, polydipsia, unconsciousness, headache or
vertigo.
Cont’d

6. PAST MEDICAL AND SURGICAL HISTORY.
MNG for last 15 years.
Surgical Hx
In past he took PPI and
anti hyperthyoid drugs
for 1 month but later on
he was not complaint .
Hospital admission for 7
days in emergency as he
had sudden complete
right side visual loss.

7. FAMILY AND PERSONAL HISTORY
Mother also suffered from multinodular goiter and never was
complaint to medicine.
Married since 40 years with 4 children they are not suffering
from any significant disease.
He ia a smoker since 45 years 1-2 pack initially.
 Sleep is not disturbed and appetite normal.
He has good social healthy term with family & friends.
Home surrounding is also clean with proper sanitation.

8. GPE EXAMINATION
An old gentleman of normal built, alert and
well oriented in time, space and person
sitting comfortably on the bed,
GCS 15/15
I/V line maintained in left forarm
Vitals:
 Pulse 89/min
 B.P: 120/80
 RR: 18/min
 BMI: 19.31
Cont’d

10.  FACE: No signs of puffiness, proptosis, xanthelasma
 TOUNGUE:dryness present ,size of toungue
normal.no sign of jaundice or cynosis.
 Colour of conjuntiva:its dirty and hazy. Rt eye has
cornea is not visible with blind eye .no sign of jaundice or
pallor
NECK
Thyroid:Inspection:enlarged swelling moving up with
deglutition and bosselated
palpation:diffuse enlarge pin size multiple nodules
consistency is firm no tenderness and no pressure effect
No sign of thyrotoxicosis berry sign –ve and pamberton sign –ve
percussion:no extension to retersternal goiter
Auscultation:No bruit
LYMPH NODE:NOT PALPABLE
FEET: NO DEFORMITY OR EDEMA

11.  GIT:
Tender epigastric region with succession
splash otherwise abdomen soft , non
tender & no visceromegaly. BS +ve
 Respiratory system:
Normal B/L vesicular breathing
with no added sounds.
 CVS: S1+S2+0
 CNS:GCS 15/15, well oriented

12. INVESTIGATION
Blood cp
WBC: 11.7
HB: 14.9 mg/dl
Plt: : 1 39
LFTS
ALKALINE
PHOSPHTASE:
144:
ALT: 20
Total bilrubin:
1.5
RFTS
UREA
CREATININE :
1.1
PT
APTT
INR
S/E
K : 4.2
FERRITIN : 11
NA : 134

13. Echocardiography:
Good Lv Systolic function
GRADE 1 DIASTOLIC DYSFUNCTION
Chamber size normal
Doppler study normal
NO RWMA SSN
ECG

14. SPECIFIC INVESTIGATION
CT SCAN ABDOMEN AND PELVIS WITH IV CONTRAST
IMPRESSION: Markedly distended stomach representing gastric
outlet obstruction with irregular thickness and pyloric growth most
likely represent gastric mass
CONCLUSION: Gastruc outlet obstruction due to an ulcerating
polypoidal mass
OPINION:poorly differentiated adenocarcinoma
(signet ring cell type)

15. DIAGNOSIS
ADENOCARCINOMA OF STOMACH

16. PRE OP MANAGEMENT
1.NG TUBE WAS PASSED
2. Cathertize the patient
3. Iv antibiotics
4. TPN
5. Arrangment of blood
6. High risk consent
7.Monitoring of electrolytes

17. LAPROSCOPIC GASTRECTOMY WITH BILLLROTH
TYPE II

19. POST OPERATIVE CARE:
 Keep patient in intensive care unit
 Strict monitoring of electrolyte balance
 Keep a check on drainage (ng,abdomianl/pelvis drains)
 Monitor hourly vitals
 Iv antibiotics
 Iv pain killers
1st OP DAY 7TH POST OP DAY
REFERRED TO NOORI HOSPITAL

21. 2:CASE PRESENTATION
• DR NOSHI KHAN
• PG T SURGERY DEPTT

22. Name : Mr.X Y Z
Age: 72yrs, male
Religion: Islam
Marital
status: Married
Profession : EX ASSISTANT
DIRECTOR
Address: ISLAMABAD
DOA: 06-10-2015 at 10 AM
BIO DATA

23. PRESENTING COMPLAINTS
Epigastric pain 3 months
Chest heaviness 3 months
with SOB

24. HISTORY OF PRESENT ILLNESS
My patient was living a healthy life 3 months back,
when he developed Epigastric pain, it was
 gradual in onset ,
 localized to epigastric region radiating laterally ,
Intermittent but recently continous & burning in
character,
mild in severity, n it relieved after taking meals.
 aggravated by food (spicy) and
 relieved by taking risek but recently it was ineffective.
 associated with bloating , dyspepsia weight loss and
epigastric fullness
 no relation of posture with pain.
Cont’d…
No h/o of haemetmesis, melena, heart
burn, large bulky greasy stools and altered
bowel habits.
He consulted a local doctor, who gave
him PPIs with which he only got temporary
relief.

25. PAST MEDICAL AND SURGICAL HISTORY:
 HTN
Surgical Hx
He is taking anti-
hypertenive drug
HAEMMORIDECTOMY
done in 1984.

26. GPE EXAMINATION
An old gentleman of normal built, alert and
well oriented in time, space and person
sitting comfortably on the bed,
GCS 15/15
I/V line maintained in left forarm
Vitals:
 Pulse 70/min
 B.P: 110/70
 RR: 18/min
 BMI: 28.1 over weight
Cont’d
PALLOR

27.  GIT:
Tender epigastric region with succession splash
otherwise abdomen soft , non tender & no visceromegaly.
BS +ve
 Respiratory system:
Normal B/L vesicular breathing
with no added sounds.
 CVS: S1+S2+0
 CNS:GCS 15/15, well oriented

28. INVESTIGATION
Blood cp
WBC: 9.6
HB: 6.3 mg/dl
Plt:
ESR: 80
LFTS
ALKALINE
PHOSPHTASE:
ALT
RFTS
UREA
CREATININE :
1.5
PT
APTT
INR
S/E
K : 4.2
FERRITIN : 11
NA : 134
HEPATITIS profile : NEGATIVE
URINE R/E : NORMAL
URINE C/S: NO GROWTH
STOOL OCULT: N/S
Chest xray : NORMAL
ECG :

29. •ECHO: GOOD LV SYSTOLIC & GRADE-
1 DIASTOLIC DYSFUNCTION
•U/S KUB LEFT RENAL CYST ,BPH
&DIVERTICULUM
•U/S ABDOMEN PYLORIC MASS,HEPATOMEGALY
&B/L RENAL CYST
SPECIFIC INVESTIGATIONS

30. DIAGNOSIS
ADENOCARCINOMA OF STOMACH

31. PRE OP MANAGEMENT
1.NG TUBE WAS PASSED
2. Cathertize the patient
3. Iv antibiotics
4. TPN
5. Arrangment of blood
6. High risk consent
7.Monitoring of electrolytes

32. LAPROSCOPIC GASTRECTOMY WITH BILLLROTH
TYPE II

34. POST OPERATIVE CARE:
 Keep patient in intensive care unit
 Strict monitoring of electrolyte balance
 Keep a check on drainage (ng,abdomianl/pelvis drains)
 Monitor hourly vitals
 Iv antibiotics
 Iv pain killers
3RD POST OP DAY

37. OBJECTIVES :
CONT…
• TO EXPLAIN THE ANATOMY OF STOMACH.
• TO DESCRIBE ABOUT HISTOPATHOLOGY AND BLOOD SUPPLY
• TO CLASSIFY GASTRIC CA.
• TO EXPLAIN REGARDING TNM STAGING.
• TO DISCUSS SIGN & SYMPTOMS.
• HOW TO INVESTIGATE AND MANAGE GASTRIC CA

38. ANATOMY:
The stomach J-shaped. The stomach has two surfaces (the anterior & posterior), two curvatures (the greater &
lesser), two orifices (the cardia & pylorus). It has fundus, body and pyloric antrum.
The stomach begins at the gastroesophageal junction and ends at the duodenum. The stomach has 3 parts. The
uppermost part of the stomach is the cardia, and the largest and middle part is called the body. The distal portion of
the stomach, the pylorus, connects to the duodenum.
These anatomic zones have distinct histologic features. The cardia contains predominantly mucin-secreting cells.
The fundus (ie, body) contains mucoid cells, chief cells, and parietal cells, while the pylorus is composed of mucus-
producing cells and endocrine cells.
. Approximately 40% of cancers develop in the lower part, 40% in the middle part, and 15% in the upper
part, and 10% involve more than one part of the organ

39. BLOOD SUPPLY:ARTERIAL SUPPLY
a. The left gastric artery
b. Right gastric artery
c. Right gastro-epiploic artery
d. Left gastro-epiploic artery
e. Short gastric arteries
The corresponding veins drain into portal system.
The lymphatic drainage of the stomach corresponding
its blood supply.

40. LYMPH NODES
Gastric Lymphatics
Numbering of the gastric and upper abdominal node stations
Station no. Anatomical location
1, 2 Adjacent to the cardia (perigastric)
3, 4 Adjacent to lesser and greatercurve
5 Suprapyloric (right gastric artery)
6 Infrapyloric
7 Left gastric artery
8 Common hepatic artery
9 Coeliac artery
10 Hilum of the spleen
11 Splenic artery
12 Hepaticoduodenal ligament
13 Behind pancreatic head
14 At the root of the mesentery (superior mesenteric artery)
15 Middle colic artery
16 Para-aortic

41. STOMACH 4 ZONE OF LYMPHATIC DRAINAGE
I – 2/3 lesser curvature & large part of the body
Lt gastric nodes  Celiac nodes
II – distal part of lesser curvature & pylorus
 Rt. gastric nodes  Supra-pyloric nodes
 Hepatic nodes Celiac & Aortic LN

42. STOMACH 4 ZONES OF LYMPHATIC DRAINAGE
III- lt. part of greater curvature LGE nodes Pancreatic –Lineal
nodes  Celiac
IV- rt. part of the greater curvature and pylorus  RGE nodes 
Pyloric nodes ( ant. surface of the pancreas)  Supra-pyloric (
along gastro-duodenal artery)  Hepatic nodes

43. STOMACH RELATIONS AND HISTOLOGY
Mucosa
Epithelium, lamina propria, and muscularis
mucosae*
Submucosa
Smooth muscle layer
Subserosa
Serosa

44. EPIDEMIOLOGY
 Gastric cancer is the second most common fatal cancer in the world
wide with high frequency in Japan.
 The disease presents most commonly in the 5th and 6th decades of life
and affect males twice as often as females.
Contn…

45. Etiological Factors of Gastric Cancer
Gastric
Cancer
H. Pylori
Genetic
factors
Envionmental
factors
Precancerous
changes
Blood group A
Male gender
Family history
Atrophic gastritis
Chronic gastric ulcer
Adenomatous polyps
Achlorhydria
Polyposis syndrome
Previous gastric resection
Menetrier disease
Micronutrition
Eating salted /smoked food
Diets high in nitrates and pickled food
Poor food storage
Lower socioeconomic status
Diet deficient inVegetable/fruit
Tobacco /alcohol/smoking

46. MULTISTEP PATHWAY IN THE PATHOGENESIS OF GASTRIC
CANCER

47. TYPES OF GASTRIC TUMORS

49. PATHOLOGY OF GASTRIC (MALIGNANT)
TUMOURS:
 The gastric cancer may arise in the antrum
(50%), the gastric body (30%), the fundus or
oesophago-gastric juntion (20%).

50. PATHOLOGIC CLASSIFICATIONS
Borrmann’s Gross Morphology
Lauren’s Histopathology (cohesiveness)
WHO Histopathology (grade and growth)
Ming Histopathology (growth and pattern)
Goeski Histhopathology (atypia & mucin)

51.  Early Gastric Cancer:
Defined as cancer which is confined to the mucosa and
submucosa regard- less of lymph nodes status.
 Advanced Gastric Cancer:
Defined as tumor that has involved the muscularis propria of
the stomach wall.

52. Early Gastric Cancer
The term 'early gastric cancer' is used to describe
tumours confined to the gastric mucosa and submucosa,
irrespective of nodal status, and was elaborated in 1962
by the Japanese Society of Gastroenterological
Endoscopy
Type I Exophytic lesion extending into the gastric lumen
Type II Superficial variant
II A Elevated lesions with a height no more than the
thickness of the adjacent mucosa
II B Flat lesions
II C Depressed lesions with an eroded but not
deeply ulcerated appearance
Type III Excavated lesions that may extend into the
muscularis propria without invasion of this layer by actual
cancer cells
52

53. GASTRIC CARCINOMA
 Diffuse(70%)
 M:F 1:1
 Onset Middle Age
 5 yr surv overall <10%
 Aetiology
 Diet
 H. pylori
 Intestinal(30%)
 M:F 2:1
 Commonly seen in elderly men
 Distal stomach
 5 yr surv overall 20%
 Aetiology
 Unknown
 Blood group A association
 H. pylori
LAURENS CLASSIFICATION

54. ADVANCED GASTRIC CANCER:
 The vast majority of gastric cancer are of advanced which deeply penetrate the stomach wall,
invade the adjacent structures with lymphatic & haematogenous metastasis.
 Advanced gastric cancer classified according to the Bormann's morphologic description as –
 Borrmann I: Fungating
 Borrmann II: Carcimatous ulcer without infiltrating surrounding
mucosa
 Borrmann III: Carcimatous ulcer with infiltration of surrounding
mucosa
 Borrmann IV: Diffuse infiltrating carcinoma

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

56. TX-Primary tumor cannot be assessed
T0- No evidence of primary tumor
Tis- intraepithelial,without invasion of lamina propria
T1- tumor invades lamina propria or submucosa
T2- tumor invades the muscularis propria
T3- tumor penetrates the serosa without invading adjacent structures ;
T4- Tumor invades adjacent structures

57. TNM Classification of Carcinoma of the Stomach-contd.
Regional lymph nodes (N)
NX Regional lymph node(s) cannot be assessed
N0 No regional lymph node metastasis
N1 Metastasis in 1 to 6 regional lymph nodes(perigastric groups)
N2 Metastasis in 7 to 15 regional lymph nodes(coeliac groups)
N3 Metastasis in more than 15 regional lymph nodes(para-aortic groups)
Distant metastasis (M)
MX Distant metastasis cannot be assessed
M0 No distant metastasis
M1 Distant metastasis
Lymph node station numbers as defined by the Japanese Gastric Cancer
Association
23 July 2016DR. RUBEL,SBMC
57

58. EVALUATION OF GASTRIC CANCER:
 History
 Clinical Examination
 Investigations
 The clinical features of gastric cancer may arise
from local disease, its complications or its
metastases.

59. CLINICAL FEATURES
 SYMPTOMS
 CLASSICAL HUNGER PAIN
 DISTENSION OF UPPER ABDOMEN WITH EPIGASTRIC FULLNESS
 VOMITTING
Projectile
Nature: Solids, then liquids
Type: Bile stained or not
Timing: Usually within an hour of a meal
1. Often asymmtomatic until late
stage
2. Weight loss due to anorexia and
early satiety is the most common
symptoms
3. Chronic occult blood loss is
common;
GIT bleeding (5%)
5. Dysphagia (cardia involvement)
6. Cachexia

60.  SIGNS
 Look at the patient!
 Dehydrated
 Cachecxic
 Basic observations
 Tachycardia
 Examination
 Often unremarkable
 VISIBLE GASTRIC PERISTALSIS
(Stomach that you Feel)
 SUCCESSION SLASH
(Stomach that you hear)

61. Clinical Manifestation:
6. Paraneoplastic syndromes ( Trousseau’s syndrome –
thrombophlebitis; acanthosis nigricans – hyperpigmentation
of axilla and groin; peripheral neuropathy)
7. Signs of distant metastasis:
a. Hepatosplenomegally with ascites& jaundice
b. Krukenbergs tumor(enlarged ovaries on p/E
c. Blummers shelf i.e fullness in the pelvis cul –de- sac ( drop
metastasis)
d. Virchow’s node (enlarged supraclavicular nodes)
e. Sister Joseph node i.e infilteration of umblicus.(pathognomonic
of advances dse)

62. SPREAD OF GASTRIC CANCER:
 The diffuse type spreads rapidly through the submucosal and
serosal lymphatic and penetrates the gastric wall at early stage
 the intestinal variety remains localized for a while and has
less tendency to disseminate.
The spread by:
1. Direct (loco regional)
2. Lymphatic
3. Blood (Haematogenous)
4. Transcoelomic

63. Lab Studies
The goal of obtaining laboratory studies is to assist in determining optimal therapy.
A complete blood cell count
can identify anemia, which may be caused by bleeding, liver dysfunction,
or poor nutrition. Approximately 30% of patients have anemia.
Electrolyte panels and liver function tests
also are essential to better characterize the patient's clinical state.
Carcinoembryonic antigen (CEA)
is increased in 45-50% of cases.
Cancer antigen (CA) 19-9
is elevated in about 20%of cases.
63

64. INVESTIGATIONS:
A. Upper gastero intestinal endoscopy
with multiple biopsy and brush
cytology
B. Radiology:
 CT Scan of the chest and abdomen
 USS upper abdomen
 Barium meal
C. Diagnostic 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.

65. 1.UGIS (double contrast)
2.Endoscopy (Biopsy / Ultrasound)
 GOLD STANDARD
 Best pre-operative staging
 Needle aspiration of LN w/ ultrasound guidance
 Can even give preop neoadjuvant tx
3.CT scan (intravenous and oral contrast):
 For pre-operative staging
4.Whole body Positron Emission Tomography scanning (PET):
 Tumor cell preferentially accumulate positron-emitting 18F
fluorodeoxyglucose.
5.Laparoscopy
Investigations for patients with gastric cancer

66. 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

67. GOAL OF TREATMENT
 Optimize the patient
 Resection of all tumor
 All margins (proximal, distal, and radial) should be negative
and an adequate lymphadenectomy performed
 Negative margin of at least 5 cm
 PosTop care of patient nutritonal &
dietery status.

68. STEP OF MANAGEMENT:
 1. extent of surgical resection
 A. proximal tumour
 B mid body tumour
 C distal tumour
 Endoscopic treatment
 EMR (endoscopic mucosal resection)
 Ablation
 Laproscopic gastric resection
 2.extent of lymphadenectomy
 3. adjuvant therapy
 Adjuvant combined modality therapy
 Neoadjuvant therapy chemotherapy
 4. palliative therapy
The extent of gastric
resection depends on:
- Tumor size
- location
- Depth of invasion
- Histological type

69. 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

70. 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

71. TREATMENTS OF GASTRIC CANCER:
 Surgery (Early or Advanced Cancer)
 Proximal tumours which involve the fundus, cardia or body (total
gasterectomy)

72. DISTAL TUMOURS WHICH INVOLVE THE LOWER ½ (SUB-
TOTAL OR PARTIAL GASTERECTOMY).

73. THE RESIDUAL TUMOR (R) CLASSIFICATION
The absence or presence of demonstrable residual tumor after
conclusion of the treatment (UICC)
R0 resection -no demonstrable residual tumor
R1 resection- microscopically demonstrable
residual tumor (e.g. diseased residual margin)
R2 resection – macroscopically visible tumor
Distinction between primary palliative intervention
(R1&R2) vs. potentially curative ones (R0)

74. CARCINOMA UPPER THIRD
Carcinoma of middle third
Carcinoma of lower third

75. 23 July 2016DR. RUBEL,SBMC
75
Surgical Treatment-contd.
The main controversy relates to the extent of lymph node dissection. Types of resective surgery have been
classified based on this criterion as follows:
1. R1: complete removal of perigastric lymph nodes;
2. R2: resection of perigastric nodes and those along the left gastric, splenic, and right hepatic
arteries;
3. R3: R2 with dissection of celiac axis nodes;
4. R4: R3 with dissection of paraaortic nodes.
Five-Year Survival Rate of Patients with Stomach Cancer
Tumor stage % Survival
R1 resection R2 resection
IA 88 91
IB 56 85
II 39 58
IIIA 7 30
IIIB 0 12

76. WHAT IS THE IDEAL EXTENT OF LYMPHADENECTOMY ?
D0- removes less than all relevant N1 nodes
D1- removes N1 nodes only
- Lt and Rt cardiac
- Lt and Rt gastro-epiploic
- Sub and Supra pyloric
D2- removes all N1 and N2 nodes
- Lt gastric
- Common hepatic
- Celiac
- Splenic hilum and along splenic artery
D3- removes all N2 and N3 nodes

77. EXTENT OF LYMPHADENECTOMY
 The Japanese Research Society for Gastric Cancer numbered the lymph node
stations that potentially drain the stomach
Generally these are grouped into
 level D1 ( stations 3 to 6),
 level D2 ( stations 1, 2, 7, 8, and 11) &
 level D3 ( stations 9, 10, and 12) nodes
 D1 nodes are perigastric
 D2 nodes are along the hepatic and splenic arteries
 D3 nodes are the most distant

78. LYMPHADENECTOMY
The extent of resection is described as
 D1. Limited Lymphadenectomy. All N1
Nodes removed en bloc with the stomach
 D2. Systematic Lymphadenectomy. N1 &
N2 nodes en bloc with stomach
 D3. Extended Lymphadenectomy. A more
radical en bloc resection including N3
nodes

79. POST OP COMPLICATIONS
Early complications
 Paralytic ileus.
 Leakage from suture line.
 Leakage from duodenal stump.
 Acute Cholycystitis, Pancreatitis
 Stomal obstruction.
Late complications
• Early Dumping syndrome
• Late dumping syndrome.
• Bilious vomiting.
• Gastric stump cancer
• Vit B12 deficiency
• Osteoporosis

80. NEO ADJUVANT CHEMOTHERAPY
 Downstaging of disease to increase resectability,
 Decrease micrometastatic disease burden prior to surgery
 Allow patient tolerability prior to surgery
 Determine chemotherapy sensitivity
 Reduce the rate of local and distant recurrences, and ultimately
improve survival.

81. CHEMOTHERAPY
 Chemotherapy for gastric
cancer
(Pre-operatve & post-
operative)
 The most widely used regimen is
5-FU, doxorubicin, and
mitomycin-c. The addition of
leukovorin did not increase
response rates.
 Radiotherapy
(Pre-intra & post-
operatively)
 Radiotherapy- studies show
improved survival, lower rates of
local recurrence when compared to
surgery alone.
 In unresectable patients, higher 4
year survival with mutimodal tx, in
comparison to chemo alone.
RADIOTHERAPY

82. PALLIATIVE CARE
 Radiotherapy provides relief from bleeding, obstruction, and pain
in 50-75%
 Median duration of palliation is 4-18 months.
 Advanced Unresectable Disease
 Surgery is for palliation, pain, allowing oral intake
 Wide local excision, partial gastrectomy, total gastrectomy, simple
laparotomy, gastrointestinal anastomosis, and bypass for food intake or
pain relief

83. RESULTS OF THERAPY – STOMACH CANCER
 Surgery with curative intent
 42% of patients
 5 year survival – 60%
 Node positive - 35%
 Node negative - 88%

84. SUMMARY

85. HAVE WE MET OUR OBJECTIVES?
 Do we know the different types of obstruction?
 Do understand the symptomatology?
 Do we know the concepts of initial management?

86. QUESTIONS?