Surgery notes

Stomach

- Ashutosh Kashyap
SKN Medical College
Pune
(Quick links: Click topics or check pdf outlines)
 Surgical anatomy LAO ISAO

-
Parts cardio Notch
Abdominal
oesophagus -

f- -
fundus

- card ia

Lesser curvature → -
Body
Angular Incisor# -
Greater curvature

⇐
^

Duod
pyloric Antrum
Pyloric canal

- Blood
-
supply .
Arteries
-

( shqort
Gastric art .

coeliac trunk ✓

splenic artery
↳ Lt .

Gastric

→
t.H.e.io
.

properties:
.

↳ I
Gastro duodenal → Rt Gastro epiploic
.

artery

.
Short gastric arteries course through gastrosplenic ligament .

. Left gastric artery is dominant artery of stomach .

[ Artery

Artery
that

that
bleeds in

bleeds in
Mallory

type 4
weiss tear

Gastric ulcer .

'
stomach does not undergo necrosis even after ligating 2
vessels because of extensive submucosal anastomosis btw
vessels .
 -
Lymphatics

"tri#
Letts

coeliac . → pancreatospienic nodes

→ .

SAQ Diagram Hepatic →

→

⇐
← Left gastro ip , .ie
, /

I
(C)

In 1
i.
..
.

Suprap,110hL ↳
nodes
. .
= Right gastroepiploic nodes
stubpyloric nodes

-
Drainage

:::::::
Lymph Nodes of 4 zones

+
Cistern a chilli

→
Lymphatics from half of stomach drain into Lt gastric splenic pancreatic nodes
proximal .

,
&
sup .
.

→
From antrum ,
it drains into Rt -

gastric .
Rt -

gastro epiploic & sub pyloric nodes .

it drains
→
From
pylorus ,
into Rt -

gastric & sub pyloric lymph nodes .

→
Efferent lymphatics from supra pyloric region drain into para
-

aortic lymph nodes & so into Lt .

super -

adavicular lymph nodes .

Efferent lymphatics from sub pyloric nodes →

superior mesenteric nodes .

oesophago gastric junction

→

Lymphatics near communicate E oesophageal lymphatics .

In Ca if blocked
stomach lymphatics retrograde spread through lower lymphatics
→
occurs
, upper are ,
.

→
Diff .
resections classified in Ca stomach based on level of lymph nodes in abdomen ÷

RO ,
RI ,
R2
,
R3 or Dl
,
D2 ( dissection)
t t s >

No Microscopic Macroscopic Inoperable

residual residual residual

Disease disease disease

 • Nerve supply .
parasympathetic
-
-
Vagus

left vagus Right vagus

1 1
Anterior trunk Posterior trunk
+ how'

Hepatic
/I ↳ Criminal nerve of Grassi

branch # "did
11
Nerve of
%earg.ge

µ
pylori
w 's foot

Anterior nerve of latarjet

Crow 's foot

-
Parasympathetic nerves are motor & secretornotor in function .

Their stimulation causes motility 4 secretion of acid .

.
Nerves of Iatarjet are mainly responsible for acid secretion .

Duringvagotomy :

a) off motor branch to pylorus out → Gastric stasis

1
Carry out drainage procedures

FHeineke-mikuli.cduodenostomy
→
z Pyloroplasty
Jaboulay gastro

b) It hepatic branch cut →

Gallbladder contraction affected
1
stasis
Iv
causes gallstone formation

Nerve of Grassi often missed

is
during vagotorny
- .

This leads to recurrence .

( Hence called criminal nerve ) .

.
sympathetic -

To -

to spinal nerves i Sphlancnic nerves ; hepatic plexus ; coeliac plexus .

↳
Functions -

① vasomotor
② motor -
to pyloric sphincter ( inhibitory to rest of musculature)
③ sensory → Chief pathway for pain sensations .
 Histological layers

-
mucosa : -
Epithelium -

Columnar

-
lamina propria

-
muscular's mucosa .
Inner circular layer

f-
-
middle
Outer
longitudinal layer
circular layer

submucosa.mu#isaerna
-

: 3 layers -
① Oblique
[ ② circular
③ longitudinal

-
Setosa

Special cells

Secrete alkaline fluid containing

-

surface mucous cells

/
-
-

"
4%1
main

= ←
mucous Neck cells
-
Secrete acidic fluid containing mucin

Isthmus
/ -
← parietal cell .

secretes intrinsic Factor & Hd '

* stem cells -

Found
%¥

in
(
Isthmus ( btw
←

←
chief ""

G- cell

gastric pit
-

-
secretes

Enter endocrine
into

and
Pepsinogen

blood .

gastric glands)
cell
&

that
Gastric lipase

secretes gastrin
 Gastritis

.TypeA_ Autoimmune

-
Antibodies against parietal cells →
Atrophy of parietal cells .

↳ pernicious anaemia
-
Results in Hypochlorhydtia I Aehlorhiedria .

-
Antrum is not affected .

'
Hypochondria
1
High levels of gastrin from Antral a cells
1
chronic Hypergastrinaemia
1
Hypertrophy of ECL cells in body of stomach
1
Micro adenomas of ECL cells .

-
Increases risk for gastric carcinoma .

-
Typed Bateman's ( Helicobacter pylori )

^
Antrum is commonly affected .

.
Patients are prone to Peptic ulcer disease

- Pan gastritis is common manifestation .

.
Intestinal metaplasia is associated with chronic pangastritis .

-
Patients with pangastritis are more prone to gastric
carcinoma .

.
Erosive Gastritis .
Common causes are NSAIDs El alcohol .

Reflux Gastritis entergastric reflux gastric surgeries

to commonly
'

-
. Due seen after .

Conservative using bile & prokinetic

can be done chelating
'
mx

agents .
 Stress illness
'
.

sequel of serious or injury

-
Characterised by reduction in blood supply to superficial mucosa

of stomach .

'

Gastric mucosa is most sensitive mucosa to Hypovolemic

insult .

.
MK site of ischemia in G1T -

splenic flexure .

-
Cushing : seen in head injuries due to increased ICP .

*
MIC site -

Acid producing area of stomach

.
Curling :
seen in burn injuries
mic site -
Duodenum CD1 )

othe Granulomatous gastritis TB ; Crohn 's disease (Rare)

.
. -

cryptospiridiosis.ph/egmatous
-
AIDS gastritis -

Secondary to

gastritis -

Rare bacterial infection

-
Eosinophilic gastritis -

Allergic → R, with steroids & Cromoglycate

 Helicobacter pylori

-
Introduction First described by Birchen
:
.

Warren & Marshall ingested to confirm whether Koch 's postulates

could be fulfilled with respect to gastritis .

'
Urease
contains and it hydrolyses area to form ammonia .

Ammonia
being alkaline allows H pylori to survive Mosharraf
H pylori
. .
.
.

. Ammonia on antral G cells causes release of gastrin via negative

feedback loop .

Cttypergastrinemia)

-
Diseased .
Type B Gastritis
peptic Ulcers
-

'
MAL Tomas
'
Gastric Cancer ( classified as class 1
carcinogen by WHO ) .

-
Investing . BC ¢ 19C breath tests

. CL0 test on gastric biopsy .

Historically using Giemsa stain or Worth in starry stains .

culture
-

Genes for toxins A

: cag
-

vac A

-
traded Standard . -

Omeprazole 120mg bid)

f-
-

-
Bismuth subsalicylate
Tetracycline
metronidazole
Cgi d)
1500mg qid )
( 500mg tid)
× 14 days

Alternatively -

omeprazole ( 20mg bid )

f-
-

-
Amoxicillin C1G bid )
Clarithromycin csoomg bid)
Tinidazole ( 500mg bid )
× 14 days

'
in-line Omeprazole ( 20mg bid )

-f -
Amoxicillin
Levoftoxacin
( Ig bid)
( 500mg bid)
XIO days

* Standard triple therapy :

Omeprazole ( 20mg bid )
Clatithromycin ( 500mg bid )
[ Not
Amoxicillin ( Ig bid) / Metronidazole
usedanymore except in areas
( 500mg
where
bid )

Clarithromycin resistance 5154 .

 Peptic Ulcers

'
types . Duodenal ulcers ( more comma )
.
gastric Ulcers

LAO ISAO
Duodenal ulcer

.
mle site -

D1 ( 1st part of duodenum )

vagotomylppts.tt
.
Associated with acid hyper secretion .
Hence respond to

pylori is most common etiological factor .

It . silent presentation
.
Epigastric pain
-
presents with complications

.
Complies .
Bleeding CMK complication of duodenal ulcers)
- perforation

; Intractability ] Uncommon
outlet
Gastric obstruction

-
types

a) Ankers .
Have a tendency to perforate .

'
this causes peritonitis

presents with Abdominal Pain

'
-

t.ae:*:
-
Rebound tenderness ( positive Blumberg 's sign)

- DX
.
X ray chest → Shows Gas under diaphragm
↳
sign of hollow viscus perforation .

stoichiometric
ifeng.to?IEIEnifpatienti
Best investigation detect air (done only for stable pt )
'
to free -
CECT .

*kissingUkers AnteriortPostriorDuodenalU
 b) Posterior .
Have tendency to bleed

'
MK vessel that bleeds -

Gastro duodenal artery

.
presents with upper GI haemorrhage .

-
DI -

Endoscopy .

.
Rarely ,
posterior ulcers perforate into Retroperitoneum

↳ Valentino syndrome

f- mimics Acute appendicitis

Renal Vein sign
may show
↳
Gas around right kidney .

→ omeprazole
-
Management .
Medical -
PPI i H pylori eradication .

the blockers (cimetidine ranitidine)

,

• , ,

General : -
Antacids , Sucralphate Triplet Quadruple regime Tetracycline -

,
bismuth tinidazole ,
, pantoprazole
Avoid NSAIDs ,
smoking ,
Intervention depends on type of complication .

spicy foods .

a) forbkedihgUk
Endoscopic management
1
IF 2 attempts Fail
1
surgery
↳
Duodenotomy
+

Under running of vessel

[suture ligation of vessel proximal & distal to ulcer 4 placing a U stitch ]
+

Pyloroplasty ( prevent stricture)

b) perforatedU
Laparotomy
1
Modified Graham 's Repair ( Omental Patch Repair )

* DPIS are as effective as Vagotomies for decreasing acid production .

*
Vagotomies are indicated for patients who are either allergic or

resistant to PPIS .
 Gastric Ulcer
-
Risks . H .

pylori
"
NSAIDs
'
Alcohol
'

smoking
'
classification modified Johnson 's classification

¥etIh%%Tnmh%rp%I%a%%%ncisuraanaian.si
-
type .
2 ulcers present
.
one gastric d one duodenal ulcer

-
typed Pre pyloric Ulcer

-
type ulcer high up in body along lesser curvature

-
type
VI. Diffuse ulcers
.
Due to NSAIDs .

** Most common gastric ulcer that bleeds -

Type II

*A Ulcer due to Acid Hypersecretion -

Type I ,
I

vagotomyIPPIs.CI
↳
Respond to

.
silent presentation
.
pain
.

Dyspepsia
.
present with complications .

•
Complications .
perforation CMK in Gastric )
Ulcers
-

Bleeding
Intractability
.

predisposition to Gastric cancer

-

* Gastric Ulcers may give rise to Hourglass deformity ( due to fibrosis & )
stricture formation .

** All Gastric Ulcers should be biopsied to rule of Cancer .

 DI Upper GI Endoscopy
↳ "

U
"

manuever should be done to see tundal gastric ulcer .

-
Management Based on type of Ulcers
Medical -

Hz blockers ,
PPI

CAntrectomyl.IE#I-DistaI9astrectomytvagotomy/PPI
- TUIEI -
Distal Gastronomy
Sx -

preferred line of Px
↳
partial &
gastrectomy
Bil roth 1 gastro duodenal

÷÷÷÷÷÷÷÷:*
:÷:÷: :÷
anastomosis .

:÷:¥¥:
:÷:i*
 Gastric reconstruction surgeries

-
Bi}I Gastroduodenostomy

. Distal Gastronomy + End to End gastroduodenal anastomosis .

.
E¥¥→¥?axenaanasnm
If there is
Distal
Gastronomy

increased tension ,
leak can occur .

BihI

Gastrojejunostomy.io#econs?
-

similar to Bill roth II

¥2 →
M

c§ '
Closure of duodenum by sutures

Resection of antrum
'
End to side
gastrojejunal
'

& distal body of stomach anastomosis .

 §④Gastrector
'
Roux-en-Y Gastrojejunostomy

:
ftp.esirggmgiegugetsocmstromf
:
B¥%%%"imb→ny→w×ii Continuous with bowel

÷
t::::÷÷:÷÷
Associated Internal Hernias Gastrojejunostomy

|
- Ante colic Gastrojejunostomy Retrocolic
- -

•
Jejunum brought in front of .
Jejunum brought behind colon by
colon making an opening in transverse
mesocolon .

qgorynjq.mg
.
occur behind

;:{www.gntransve.s.meso.am
. µ

Petersen 's Hernia t

stammer 's Hernia
 Vagotomy

-
T# .
Division of anterior and posterior vagus before they give
hepatic and celiac branches .

-
the procedure denervates liver & biliary tree (may lead to
gallstones)

.
procedure also denervates pylorus & may lead to gastric
stasis .
Hence it is combined with a
drainage procedure .

. Drainages -

① Heineke Miku lice Dyloraplasty

longitudinal incision of pyloric ring and closure of incision

-

using transverse sutures .

pylorus -4

→ →

② Finney Dyloroplasty

③ Jaboulay Dyloroplasty ( gastroduodenostomy)

Gastrojeunostomy.truncatvagot my-Antrectomy.ci
ives maximum acid reduction .

Lowest rate of of ulcers ( Clt)

.

recurrence

. Dost operative complications and

mortality is high .

-
Rarely done ( Recurrent Ulcers ) .
 .se/ectiveVagotomy- . Division of anterior and posteriorvagus after it gives
off Hepatic and celiac branches .

'
Denervates pylorus and hence has to be combined with

drainage procedure .

Generally not preferred because it does not have

sufficient evidence of advantage over highly selective vagotonny
or of lower complications than truncal vagotomy .

.
Highly selective vagotomy .
Also known as Parietal cell Vagotomyl Proximal Gastric Vagotorny .

Division of Crow 's foot branches but stop 7cm from pylorus .

6,8cm

] - Crow's foot

.
Does not denervate liver or biliary tree .

preserves nerve supply of antrum and pylorus .

Hence , no

drainage is
procedure required
.

.
Has least postoperative complications but recurrence rate is
higher than in truncal vagotorny .

'
Recurrence rate : 2- 10%
 Complications following Vagotomy & Gastric Surgeries

① Haemorrhage during surgery

② Anastomolic leak

③ Duodenal stump blow out occurs→

on Day 4
↳ presents with abdominal pain + peritonitis

④ Ulcers at anastomotic site or

just distal to it .

⑤ Bilious vomiting
⑥ Internal Hernias -

Petersen 's & stammer's

⑦ Afferent loop syndrome -

stasis in bilio pancreatic limb

⑧ Efferent loop syndrome -

Rate

⑨ Post vagotomy diarrhoea osmotic diarrhoea

[
Octreotide is not helpful .

④ Nutritional complications :

a) Iron deficiency anemia lmk complication overall)

b) to Vitamin Bia ( pernicious anemia )
c) t calcium

d) weight loss

④ Dumping syndrome

④ Recurrence -

mostly seen with Highly selective vagotomy .

⑤ Increased risk for gastric cancer (4 × of control population)

④ Gall stones →
a late complication of truncal vagotomy .
 Dumping Syndrome

-
Group of symptoms caused due to rapid emptying of food
from stomach to duodenum : seen commonly after Gastric sx .

( more common in Bill roth I than Bill roth I)

/÷: ÷ ÷i
t.atedumping.AE#gyGastrectomy
Earpig

Rapid gastric emptying of

+ carbohydrates in duodenum
No interrogation from pyloric 1
sphincter Rapid absorption & hyperglycemia
t t
Rapid passing of hyper molar 4 insulin secretion
food from stomach to duodenum 1
1 Rebound Hypoglycemia
this triggers rapid shift of extracellular
fluid into duodenum .

1
luminal distention &
Extracellular volume loss .

:÷÷÷:÷¥÷÷÷:
"

:*:
÷

.
Cramping abdominal pain .
Confusion
.
Tachycardia
b) IV ( less common )
-

palpitations & Indistinguishable from Insulin

-
Tachycardia shocks
-
Light headedness / Dizziness

Relation to meals within 45 minutes to 1 hr

'

-
10 minutes After .

'
Relief Lying down Food

-
Aggravation more food Exercise

- Du¥ 30-40 mins .

30-40 mins .

.
Dietary modifications in dumping syndrome
'
small frequent meal
-

-
Avoid
Avoid
Avoid
simple sugars
carb rich food

liquid with meals

Ifsymp-lomspersistoctreoti.de#omssqpersit
) (somatostatin analogue
V

convert to
- Avoid sugar rich liquid
- Take High protein diet Roux -
en -

Yaastrojejunostomy
 Gastric Volvulus

Organo-axial (Horizontal) Mesentero-axial (Vertical)

I
.AM#IY Line joining GE junction of pylorus line joining lesser 4 greater
curvatures

¥, +

- incidence most common overall Cats )

cases more common in children

'
Association . Associated with diaphragmatic .
Usually not associated with
defects as Rolling hernias and diaphragmatic defects
Paraoesophageal hernias may be atw wandering spleen
.
- . .

.
Presentation .
Acute .
chronic & recurrent .

complete vascular compromise

.
partial volvulus ( 11800)
seen .
.
Vascular compromise is uncommon

'
lineatus Borchardt triad -

① severe upper abdominal pain

② Recurrent retching
③ Inability to pass Nasogastric tube .

.
Invests I0C -
CECT
* cascade sign seen on contrast study .

-
Management If stomach Necro sed -

Resection + correction of diaphragmatic defects .

If not necrosed Detorsiont Fixation by Gastro pay

-

.
 Bezoars
-
Bezoars are collection of non digestible materials .

Phytobezoar

-
Collection of non digestible material of vegetable origin .

-
Risk factors . Patients who have undergone gastric surgery ¢ have impaired
gastric emptying .

- Diabetics with autonomic neuropathy

-
C1F -
Early satiety
nausea vomiting
.

.
pain
.
weight loss

•
DX Barium meal or Endoscopy .

My .
Enzymatic debridement 1Pa pain Cellulose) followed by .

aggressive Ewald Tube lavage or Endoscopic fragmentation .

-
Surgical removal

Trichobezoar SAO
-
concretions of hair ( Hair ball ) inside stomach .

-
Associated with psychiatric disorders Ctrichophagia)
.
More common in females .

-
Ctf -
Dain ( from gastric ulceration)
'
Fullness ( from gastric outlet obstruction)

may gastric perforation

'
cause .

'
DI I0C -
CECT

IX. small trichobezoars -

Endoscopic fragmentation , vigorous lavage .

Enzyme therapy
-
large trichobezoars -

Surgical Removal .

* Rapunzel syndrome -

If a duodenal extension of trichobezoar is present .

 LAO Gastric Cancer

-
Riskf .
smoking
'
Alcohol consumption
.
Consumption of smoked food or fish
-
Preservative rich food
H
pylori
.
-

-
Gastritis type -

A Type B
and
-

Gastric surgeries and moonstruckons

-
Type A Blood group
Polyps Adenomatous polyps / True adenomas
.
-

↳
Associated with familial Adenomatous Poly posts syndrome .

;!!i
mosteommmooups.net#sIggoIIgi.igiiii:y
*

* Incidence of Gastric Ca has decreased with advent of refrigeration of food

-
site .
Most common site in western countries -

Proximal stomach

.
most common site in asia and over all -
Antrum

-
Classification

Lauren’s Classification

:|
.
Intestinal Diffuse

'
Due to environmental factors .
.
Due to familial factors

Blood

%÷÷.EE?:In::oI:iI:::::::: :* association
with

.
men 7 Women - women > men

.
Incidence increase with age -
seen in younger patients .

'
well differentiated with gland .
poorly differentiated signet Ring
,

formation cells

| qq.GG?nin/.pgz,p,g,.naq.vapion..p53.pI6
.
Haemdtogenous spread .
Trans mural 4 Lymphatic spread .

-
microsatellite instability .
Decreased E cadherin
.
loss of heterozygosity
f.
inactivation
'
Japanese classification .
Used for early gastric cancer .

. tarter -

cancer limited to mucosa $ sub mucosa

with Iwithout LN involvement .

-eEE
I.
-
type

Protuding

Yet
i
IIA. Superficial and elevated IIB. Flat IIB.
c Superficial and depressed

'I
type
tI
-

Excavated

.
Bormann Classification .
Used for advanced gastric cancer .

.tt#ed9asricCancer- Cancer which involves muscularis .

Polypoid ( Type I) Ulcerative ( Type II)

Ulcerative and infiltrating ( Type 3) Diffusely infiltrative/ Linitis plastica (type 4)

:::::::::¥::i:::::::::
* Diffusely proliferative is also known as limits plastica
↳ means leather bottle
-
Molecular Classification Described by The cancer Genome Atlas ( TC9A) group .

① Epstein-Barr
-
positive -

.
P1K 3CA mutation
.
DD -

1112 overexpression
.
Immunotherapy is useful .

② microsakstabty .
Hy permutation
-
MLH 1 silencing

③ hromIhsty . Intestinal histology

-
TP53 mutation
'
RTK RAS activation

④ GenoHstab .
Diffuse histology -
worst prognosis
RH0A mutations
'
CDHI ,

'
cell adhesions seen

'
WHO Classification WHO classifies gastric cancer in following categories :

Adenocarcinoma
-

/
-

'
Adeno squamous cell carcinoma
-

Squamous cell carcinoma

^

in:*:*:*:*:ma

According to growth pattern

papillary
Tubular
mud nous
poorly cohesive ( Includes signet Ring )
mixed
 -
IF .
Lump
-
Gastric outlet obstruction ( Early satiety , bloating vomiting )
,
.

'
Anaemia

¥
'
Anorexia
.
Dyspepsia ( New onset)
'
silent presentation
weight loss
Ds
.

** Gastric Cancers are most common cause of G00 .

Atypicalpresentations-iosistermarysosephsnoduk.pe
.

ri umbilical metastasis seen in gastric cmk) and ovarian ca .

Krukenbergtumori
②

Bilateral ovarian metastasis

-
Cancers in which this is seen -

Gastric cancer CMK)

f. Breast cancer
colorectal cancers

-
Theories Old -

I drop mets
Trans coelom ic spread
[ New -

Retrograde lymphatic spread .

③ Irish -

Left axillary lymphadenopathy .

④ VirymphNod/ Trois ier 's sign left supra aviator LN

{
- .

↳
✓
sign of advanced disease in any G1 1GU malignancy
SIGNS OF

ADVANCED ⑤ Blumer.sk#
" .
Pelvic metastasis into pouch of douglas / Retro vesical pouch in males .

Ia
""

advanced in
sign of cancer any 41 malignancy
-

.
Felt on digital Rectal exam .

⑥ mighrombopheb.is -
known as Trousseau syndrome
-
most common in Pancreatic cancers .

-
Typical of
Glucagon Oma .

⑦
leserT-relatsign.mu/HbIeseborrheickaratosis
⑧
Ridged velvety thickening in palms
-
.
 IOC -

distant spread
-

C ECT

Diagnosis .
Endoscopic biopsy

.
Overall staging -
PET CT ( 18 FD4 Used →
I,z= 110 mins )
→

EUS Lfndoscopic Ultrasound ) spread

staging
IOC local
. T and N .

-t*morinw"esm"atamsProP'M" " "m"

TNM involves lamina propria
staging •
IT a Tumor .
Mo No distant metastasis
-
-

b- Tumor involves sub mucosa

T3 Tumor involves

subserosa.TL
.
-

,
a -
Tumor perforates serosa

b- Tumor invades adjacent organs

::::::::::::::::
.
No -

NO lymph nodes

.
Nz a- Metastasis in 7- Is regional lymph nodes
b- Metastasis in 715
regional lymph nodes

* most common site for distant metastasis .

Liver
=

-
Management

Surgery
surgeryforbrimarytumor.pro/imal
-
①
f

margin -

5cm
. Distal margin -

pylorus

.
Gastrectomi.ec :
p Pylorus
-
Distal gastronomy Cantrectomy ) -

30% resection
Body
{ partial gastronomy 60-701 resection
' -

-
Subtotal gaistredomy -

got resection
-
Total gastronomy I
-

1001 resection
✓

fundus
 ② surgeryforlymphh0
Japanese divided lymph Nodes into various stations .

ft
1- Rt para Cardinal 2

¥¥er9Ir%IrefIo"m%n
-

,
.

2- Lt .

para cordial

I. "

s
-

supra pyloric
6
6- Infra pyloric

7 Lt gastric vessels

⑤
- -

[
.

8 -

common hepatic vessels a

8 to
9 -

Coealic artery Around

7
10
splenic Hilum vessels
-

11
splenic artery
-

Di lymphadenectomy Removal of stations to 6

-

- -

.
Dzlymphadenectomy -

Removal of stations 1 to II
Optimum lymph node clearance
i.
minimum number of LN removed 15 - .

*
sparing of lymph node station 10 is done in many cases of

Radical total gastredomy with Da Iymphadenectomy .

. preferred method of gastric reconstruction - Roux -

en -
Y
Gastrojejvnostomy
( oesophagojejvnal anastomosis
for total gastrectomy)

.
Chemotherapy .
For lymph node positive disease

.
ECF regimen -

Epirubicin
Cisplatin
5- Fluoro uracil

-
For bulky lymph nodes and disease 773 stage Neoadjuvant -

therapy
.
Radiotherapy .
Given to gastric bed to prevent local recurrence .

9Mt site of recurrence

-

Gastric Bed .

* Dzlymphadenectomy → stations 1- 16 .
 One liners for Gastric Cancer
•
most important prognostic factor -

T stage / depth
.
most important prognostic factor in operable disease -

LN status

.
most common site of distant metastasis -

liver

.
Drug for Her 21 new mutation -

Transtuzumab ( Herceptin )

gene mutation pembrolizumab

-
for PD11 -

↳ Approved for metastatic / recurrent

Gastric cancers .

.
Oral chemotherapy for Advanced Gastric Cancer -

tegafur-oteraa.lt Gimaracil
↳ oral ftuoropyrimidine derivative .

\
Guidelines for endoscopic resection of early gastric ca

.
Tumor 52cm
-
Tumor limited to mucosa .

No lymph o vascular invasion

- .

-
No ulceration
.
well or moderately well differentiated histo pathology .
 Gastrointestinal Stromal Tumors (GIST)

-
Arise from intestinal pacemaker cells of Cajal

- MIC site for GIST

-

stomach .

-
types

adi . more common than familial .

Presents with Carney's triad -

Gastric GIST
1-
.

Paraganglion omas

pulmonary Chondromas
-

'
familial . Known as Carney stratahis syndrome 1 Carney 's diced .

composed of Gastric GIST and paraganglionomas

'
.

'
Features .
Gastric Gists are mostly due to Succinyl dehydrogenase BCSDH)
mutation .

.
Gastric GISTS are multifocal and aggressive
.

-
they behave like sarcomas & do not metastasize to LNS .

Liver
Haematogenous spread is mic site
'
common
- .
-

Pathology Hist pathology spindle 1213) and Epithelial 's) types

'
.
On -
.

.AE/Ther'sClassif-ication.
Differentiates btw benign & malignant
.

-
Based on size of tumor
I No of mitotic
.

figures
↳
single most important prognostic factor .

Immunohistochemistry
'

-
CD11 7IC -
KIT -

most important IHC marker for GIST 1790% cases )

CD -34 in 65-701
'

: present GIST .

DOG 1 :
most specific market for GIST .

'
Wild type of GIST -
c- KIT negative
LPDGFR a negative
( platelet derived growth factor)
 -
ELF .
upper 41 haemorrhage ( MK)
-
mass
.
pain
- Perforation

.
DI .
Radiological diagnosis ( No biopsy required)

For
monitoring of GIST during therapy PET CT used
. .
-

thx surgery tumor with 2cm margin

.
. -

Reset .

-
If present in stomach -

wedge resection ( with 2cm margin)

IN clearance Not
required
•
- .

If adherent to other structure Reset other structure too

'
→ .

malignant 1 metastatic GIST

-

Imatinib ( adjuvant therapy)

-
If Imatinib resistant -

Sunitiniblsorafenib .
 Gastric lymphoma

Typed ① Primary Gastric lymphoma ( 5%)

- It is NHL -
B cell -

lymphoma
.
It is diffuse large B- cell lymphoma ( DLBCL)
^
Stomach is most common extranodal site in G1T to be involved
with lymphomas .

② stomach involved in Generalised lymphomato us process ( as %) .

-
LIE .
Lump
-
Upper 91 haemorrhage
-
Symptoms of lymphoma -

fever , Night sweats . weight loss

'
DI Endoscopic Biopsy
-
My . 1st line -

chemotherapy → R -

Rituximab
(R -
CHOP therapy) C- Cyclophosphamide
( Doxorubicin)
Hydroxy
dqunorubicin
H -

0-oncovinvincristi.no
D- Prednisolone

-
Surgery
i.
Indications ① Patient with limited gastric disease
② Pt with symptomatic
.

recurrence
Ilreatment failure .

③ complications Bleeding -

, perforation 400 ,

MALToma

-
Mucosa associated lymphoid tissue lymphoma

'
most commonly seen in stomach .

Associated with

H.pylori.MX
•

•
High grade -

Manage as lymphomas
-
Low grade -
H .

pylori eradication therapy

* stomach is most common site for lymphomas of Gl system .

↳ most common site -

Antrum .