OESOPHAGEAL & GASTRIC TUMORS

DR.MISBAH SARFRAZ

ANATOMY

● The esophagus is a 25-cm long muscular tube that connects the pharynx to the stomach.The esophagus extends from the lower border of the cricoid cartilage (at the level of the sixth cervical vertebra) to the cardiac orifice of the stomach at the side of the body of the 11th thoracic vertebra.

● The first constriction is at 15 cm from the upper incisor teeth, where the esophagus commences at the cricopharyngeal sphincter; this is the narrowest portion of the esophagus and approximately corresponds to the sixth cervical vertebra

● The second constriction is at 23 cm from the upper incisor teeth, where it is crossed by the aortic arch and left main bronchus

● The third constriction is at 40 cm from the upper incisor teeth, where it pierces the diaphragm; the lower esophageal sphincter (LES) is situated at this level[1, 2, 3]

● These measurements are clinically important for endoscopy and endoscopic surgeries of the esophagus

● The esophagus has been subdivided into 3 portions, as follows:

● The cervical portion extends from the cricopharyngeus to the suprasternal notch

● The thoracic portion extends from the suprasternal notch to the diaphragm

● The abdominal portion extends from the diaphragm to the cardiac portion of the stomach.

Blood supply● Cervical portion ---

INF THYROID ARTERY

● Thoracic portion ------- bronchial and esophageal branches of the thoracic aorta

● Abdominal portion ---ascending branches of the left phrenic and left gastric arteries

VENOUS DRAINAGE

● Venous blood from the esophagus drains into a submucosal plexus---->blood drains to periesophageal venous plexus--->Esophageal veins drain in a segmental way similar to the arterial supply, as follows:

● From the cervical esophagus---> the inferior thyroid vein

● From the thoracic esophagus,-----> the azygos veins, hemiazygos, intercostal, and bronchial veins

● From the abdominal portion---->left gastric vein; the left gastric vein is a tributary of the portal system.

LYMPHATIC DRAINAGE

Submucosal lymphatic system .The esophagus has 2 types of lymphatic vessels. A plexus of large vessels is present in the mucous membrane, and it is continuous above with the mucosal lymphatic vessels of pharynx and below with mucosal lymphatic vessels of gastric mucosa.

● The second plexus of finer vessels is situated in the muscular coat. Efferent vessels from the cervical part drain into the deep cervical nodes.

● Vessels from the thoracic part drain to the posterior mediastinal nodes and from the abdominal part drain to the left gastric nodes. Some vessels may pass directly to the thoracic duct.Lymphatic drainage of the esophagus contains little barrier to spread, and esophageal lymphatics are densely interconnected. Hence, esophagus carcinoma can spread through the length of the esophagus via lymphatics and may have nodal involvement several centimeters away from the primary lesion.

NERVE SUPPLY

● Upper 1/3rd ----Recurrent laryngeal branches of the vagus nerve supply the striated muscle.

● Motor supply to the nonstriated muscle is parasympathetic, vagus.These fibers reach the esophagus through the vagus and its recurrent laryngeal branches. They synapse in the esophagus wall in the ganglia of submucosal plexus (Meissner) and myenteric plexus (Auerbach) between the outer longitudinal and inner circular muscle fibers supply mucous glands and smooth muscle fibers within the walls

Vasomotor sympathetic fibers that supply the esophagus arise from the upper 4-6 thoracic spinal cord segments.The axons of these neurons innervate the vessels of the cervical and upper thoracic esophagus and distil esophagus.

HISTOLOGY

● Histologically, the esophagus has the following 4 concentric layers (see the image below)[3] :

● Mucosal layer● Submucosal layer● Muscular layer● Adventitial layer

STOMACH

● The stomach is the first intra-abdominal part of the gastrointestinal (GI), or digestive, tract. The stomach lies in the left upper quadrant of the abdomen.The thoracic esophagus enters the abdomen via the esophageal hiatus of the diaphragm at the level of T10. The abdominal portion of the esophagus has a small intra-abdominal length (2-3 cm). The esophagogastric junction (cardia), therefore, lies in the abdomen below the diaphragm to the left of the midline at the T11 level.

● The cardiac notch (incisura cardiaca gastri) is the acute angle between the abdominal esophagus and the fundus of the stomach, which is the part of stomach above a horizontal line drawn from the cardia. The body (corpus) of the stomach leads to the pyloric antrum (at the incisura angularis). The pyloric antrum narrows toward the right to become the pyloric canal, surrounded by the pyloric sphincter, which joins the duodenum at the L1 level (transpyloric plane) to the right of the midline .

RELATIONS

● The anterior surface of stomach is related to the left lobe of the liver the anterior abdominal wall, and the distal transverse colon. The posterior surface of the stomach is related to the left hemidiaphragm, the spleen, the left kidney, and the pancreas (stomach bed).

● The omental bursa (lesser sac) lies behind the stomach and in front of the pancreas; it communicates with the greater sac (main peritoneal cavity) via the omental (epiploic) foramen (of Winslow) behind the hepatoduodenal ligament.

● The convex greater curvature of the stomach starts at the left of the cardia and runs from the fundus along the left border of the body of the stomach and the inferior border of the pylorus. The concave lesser curvature starts at the right of the cardia as a continuation of the right border of the abdominal esophagus and runs a short distance along the right border of the body of the stomach and the superior border of the pylorus. The junction of the vertical and horizontal parts of the lesser curvature is called incisura angularis.

● The stomach and the first part of the duodenum are attached to the liver by the hepatogastric ligament (the left portion of the lesser omentum), to the left hemidiaphragm by the gastrophrenic ligament, to the spleen by the gastrosplenic/gastrolienal ligament containing short gastric vessels, and to the transverse colon by the gastrocolic ligament (part of the greater omentum). Few peritoneal bands may be present between the posterior surface of the stomach and the anterior surface of the pancreas.

● Part of the greater omentum hangs like an apron from the transverse colon, with 4 layers of the peritoneum (often fused): 2 layers go downward from the stomach and then run upward to be attached to the transverse colon.

BLOOD SUPPLY

●The celiac trunk (axis) arises from the anterior surface of the abdominal aorta at the level of L1. It has a short length (about 1 cm) and trifurcates

into the common hepatic artery (CHA), the splenic artery, and the left gastric artery (LGA).

●The LGA runs toward the lesser curvature of the stomach and divides into an ascending branch

(supplying the abdominal esophagus) and a descending branch (supplying the stomach).

● The CHA runs toward the right on the superior border of the pancreas and gives off the gastroduodenal artery (GDA), which runs down behind the first part of the duodenum. After giving off the GDA, the CHA continues as the proper hepatic artery.The right gastric artery, a branch from the proper hepatic artery, runs along the lesser curvature from right to left and joins the descending branch of the LGA to form an arcade along the lesser curvature supplying body of stomach.

● The GDA divides into the right gastro-omental (gastroepiploic) artery (RGEA) and the anterior superior pancreaticoduodenal artery (SPDA); it also gives off the small supraduodenal artery (of Wilkie). The RGEA runs along the greater curvature from right to left.The splenic artery runs toward the left on the superior border of the distal body and tail of pancreas and gives off the left gastro-omental artery (LGEA),

●which runs from left to right along the greater curvature and joins the RGEA to form an arcade

along the greater curvature between the two leaves of peritoneum of the greater omentum.

● The greater curvature arcade formed by the RGEA and the LGEA provides several omental (epiploic) branches to supply the highly vascular greater omentum. The splenic artery also gives off 3-5 short gastric arteries that run in the gastrosplenic ligament and supply the upper part of the greater curvature and the gastric fundus. The stomach has a rich network of vessels in its submucosa.

VENOUS DRAINAGE

● The left gastric (coronary) vein drains into the portal vein at its formation (by the union of the splenic and superior mesenteric veins). The right gastric and right gastro-omental veins drain into the portal vein. The left gastro-omental vein drains into the splenic vein, as do the short gastric veins.

● The gastrocolic trunk is present in a large number of cases and lies at the junction of the small bowel mesentery and the transverse mesocolon. It may drain the right colic, middle colic, and right gastro-omental veins.

● The short gastric arteries and veins are sometimes collectively referred to as the vasa brevia.

LYMPHATIC DRAINAGE

NERVE SUPPLY

● The esophageal plexus of vagus (para-sympathetic) nerves lies in the posterior mediastinum below the hila of the lungs. It divides into 2 vagal trunks that enter the abdomen along with the esophagus through the esophageal hiatus in the left dome of diaphragm. The right (posterior) vagus is behind and to the right of the intra-abdominal esophagus, whereas the left vagus is in front of the intra-abdominal esophagus.

● The right vagus gives off a posterior gastric branch called the criminal nerve of Grassi, which traverses to the left and supplies the cardia and fundus of the stomach; the nerve is so called because it is often missed during vagotomy and is then responsible for recurrence of peptic ulcer. The right vagus gives off a celiac branch (which supplies the pancreas and the small and large bowel), and the left vagus gives off a hepatic branch (which supplies the liver and the gallbladder).

● After giving off the celiac and hepatic branches, respectively, the right and left vagal trunks continue along the lesser curvature of the stomach (in close company with the vascular arcade formed by the left and right gastric vessels) as the posterior and anterior gastric nerves of Latarjet, which supply the corpus (body) of the stomach, the antrum, and the pylorus.

HISTOLOGY● The innermost lining of the

stomach wall is mucosa, which consists of columnar epithelium, lamina propria, and muscularis mucosa. Submucosa contains a rich network of blood vessels and Meissner’s nerve plexus. The smooth muscles of the stomach are arranged in 3 layers: inner oblique (unique to stomach), middle circular (forms the pylorus), and outer longitudinal. These muscles are supplied by the Auerbach’s nerve plexus. Serosa is the visceral peritoneum that covers most of the stomach. Mucosa and submucosa are thrown into several longitudinal folds called rugae.

● The lower esophageal sphincter (LES), or gastroesophageal sphincter, is not a true (anatomic) sphincter; however, the pylorus is a true sphincter composed of circular muscles.

● The lower esophageal sphincter (LES), or gastroesophageal sphincter, is not a true (anatomic) sphincter; however, the pylorus is a true sphincter composed of circular muscles.

BENIGN TUMORS ESOPHAGUS

● Benign tumours of the oesophagus account for less than 1% of all oesophageal neoplasms. Leiomyomas are the most common; rarer entities include papillomas, fibrovascular polyps, granular cell tumours, adenomas, haemangiomas, neurofibromas, and lipomas.

● Leiomyomas are smooth-muscle tumours arising in the oesophageal wall. They are usually solitary, well encapsulated with an intact overlying mucosa, and grow slowly. Most small (>5 cm) leiomyomas are asymptomatic and are incidental finding on barium study .

MALIGNANT TUMOR OESOPHAGUS

● Cancer in the upper two-thirds is a squamous cell carcinoma and one in the lower one-third is an adenocarcinoma.

● RARE

leiomyosarcoma, malignant melanoma, rhabdomyosarcoma, lymphoma ,muco-epidermoid carcinoma, small cell carcinoma, adenoid cystic carcinoma, adenosquamous carcinoma.

FACTORS ASSOCIATED WITH CARCINOMA ESOPHAGUS

● Smoking , History of aerodigestive tract malignancy*

● Alcohol consumption, Achalasia*● Hot beverages* ● N-nitroso compounds* Plummer vinson

(paterson kelley) syndrome*● Betel nut chewing*● Deficiencies of*:● Green vegetables Barrett's oesophagus†● Vitamins A, C and E

● in the past three decades was the increase in incidence of adenocarcinomas of the lower oesophagus and gastric cardia. Gastro-oesophageal reflux disease, obesity, and the pre-malignant condition of Barrett's oesophagus.Barrett's oesophagus is a condition in which the squamous epithelium of the distal oesophagus is replaced by a columnar epithelium characterized by the presence of specialized intestinal metaplasia.. The Barrett's epithelium progresses through low-grade to high-grade dysplasia to invasive cancer.

CLINICAL FEATURES● 50 years of age● male predominance.● Dysphagia is the most common symptom, and is

rapid in onset, progressing from difficulty in swallowing solid food and later to liquid within a matter of weeks. Symptom of dysphagia is usually not felt until the tumour is advanced.

● Regurgitation (GERD)● , loss of weight,Haemorrhage

Cervical lymph nodes

Substernal pain or discomfort● Hoarseness signifies recurrent laryngeal nerve

palsy from direct tumour infiltration or from lymphatic spread and is thus a poor prognostic sign.

● Coughing or choking on eating may be due to aspiration, predisposed by the presence of vocal cord palsy if present, or the development of an oesophageal-respiratory fistula.

● Squamous cell cancers of the oesophagus rarely bleed.

● Fistulas may develop between the esophagus and the trachea, increasing the pneumonia risk;cough, fever or aspiration.

Hematogenous Spread:liver metastasis could cause jaundice and ascites, lung metastasis could cause shortness of breath, pleural effusions.

INVESTIGATIONS

● GENERAL: CBC ● LFT● RFT● BLOOD GLUCOSE ● VIRAL MARKERS● CHEST X RAY

INVESTIGATIONS

● SPECIFIC:

UPPER GI ENDOSCOPY AND BIOPSY● A barium swallow identifies the location and

length of oesophageal narrowing, mucosal irregularity, dilatation of the proximal oesophagus.

● CT SCAN● LAPAROSCOPY,LARYNGOSCOPY,

THORACOSCOPY,BRONCHOSCOPY

Stage groupings for oesophageal cancer

● T: Primary tumour● Tx Tumour cannot be assessed● Tis In situ carcinoma● T1 Tumour invading lamina propria or the

submucosa, does not breach submucosa● T2 Tumour invading into but not beyond the

muscularis propria● T3 Tumour invades the adventitia but not the

adjacent structure● T4 Tumour invades the adjacent structure

● N: Regional lymph nodes*● NX Regional nodal status cannot be assessed● N0 No regional lymph node involvement● N1 Regional lymph node involved● M: Distant metastases● Mx Distant metastases cannot be assessed● M0 No distant metastasis● M1a Upper thoracic oesophagus with

metastases to cervical nodes.

● Lower thoracic oesophagus with metastases to coeliac nodes

● M1b Upper thoracic oesophagus with metastases to other non-regional nodes or other distant sites

● Lower thoracic oesophagus with metastases to other non-regional nodes or other distant sites

● Middle thoracic oesophagus with metastases to cervical, coeliac, other non-regional nodes or other distant sites.

● For cervical oesophageal cancer, regional nodes are the cervical nodes. For intrathoracic cancers, the mediastinal and perigastric nodes (excluding coeliac nodes), are considered regional.

TNM STAGING● Stage 0 Tis N0 M0● Stage I T1 N0 M0● Stage IIa T2 N0 M0● T3 N0 M0● Stage IIb T1 N1 M0● T2 N1 M0● Stage III T3 N1 M0● T4 N0;N1 M0● Stage IVa Any T Any N M1a● Stage IVb Any T Any N M1b

● Endoscopic ultrasonography (EUS) is best in T-stage and regional nodal (N) staging.Recent advances also allow EUS-guided fine needle aspiration cytology of suspicious lymph nodes to be carried out.

PRINCIPLES OF TREATMENT● Patients with early disease generally do well

with surgical resection, provided an R0 resection (curative procedure with macroscopic and microscopic clear margins) can be performed.Patients with local-regional advanced disease, upfront combined treatments including chemotherapy and radiotherapy are often used, and subsequent surgical resection depending on response. There is, however, no clear evidence that this gives superior result to surgical resection alone.

OPERATIVE TREATMENT

● Potential surgical candidates should have a careful risk assessment especially with regards to cardiopulmonary status. Smoking should be stopped and active chest physiotherapy instituted.

● Pre-operative enteral nutrition or parenteral nutrition may be beneficial.

OPERATIVE TREATMENT

● Potential surgical candidates should have a careful risk assessment especially with regards to cardiopulmonary status. Smoking should be stopped and active chest physiotherapy instituted.

● Pre-operative enteral nutrition or parenteral nutrition may be beneficial.

ENDOSCOPIC MUCOSAL RESECTION

● Forms of endoscopic therapy have been used for Stage 0 and I disease: endoscopic mucosal resection (EMR) and mucosal ablation using radiofrequency ablation, photodynamic therapy, Nd-YAG laser, or argon plasma coagulation.

● The major complications of endoscopic mucosal resection include postoperative bleeding, perforation and stricture formation.

● If the person cannot swallow at all, an esophageal stent may be inserted to keep the esophagus open; stents may also assist in occluding fistulas. A nasogastric tube may be necessary to continue feeding while treatment for the tumor is given, and some patients require a gastrostomy /iliostomy(feeding hole in the skin that gives direct access to the stomach). The latter two are especially important if the patient tends to aspirate food or saliva into the airways, predisposing for aspiration pneumonia.

Oesophagectomyis the removal of a segment of the esophagus; as this shortens the length of the remaining esophagus, some other segment of the digestive tract (typically the stomach or part of the colon or jejunum) is pulled up to the chest cavity and interposed.[29] If the tumor is unresectable or the patient is not fit for surgery, palliative esophageal stenting can allow the patient to tolerate soft diet.

Types of esophagectomy:

The thoracoabdominal approach opens the abdominal and thoracic cavities together.The two-stage Ivor Lewis (also called Lewis–Tanner) approach involves an initial laparotomy and construction of a gastric tube, followed by a right thoracotomy to excise the tumor and create an esophagogastric anastomosis.The three-stage McKeown approach adds a third incision in the neck to complete the cervical anastomosis.

●Lewis-Tanner (Ivor Lewis) operation● For tumours of the middle and lower third of the

oesophagus.The stomach, the blood supply of which is based on the right gastric and right gastroepiploic vessels, is mobilised via laparotomy. A pyloroplasty or pyloromyotomy is performed to enhance gastric drainage. The oesophagus is then resected through a right thoracotomy. The stomach is delivered up into the thorax via the diaphragmatic hiatus to anastomose with the divided oesophagus near the apex of the thoracic cavity.

● In type II and III tumours around the gastrooesophageal junction, an extended total gastrectomy with a distal oesophageal resection is often performed, although some surgeons advocate a proximal gastric and distal oesophageal resection. Both can be accomplished via the abdomen or with an additional thoracotomy.

● In tumours of the upper thoracic oesophagus, oesophagectomy can be performed through a right thoracotomy, then by simultaneous left cervical and abdominal incisions the stomach can be prepared and delivered up to the neck for anastomosis

McKeown's procedure ● A three-phase oesophagectomy. The colon is

placed in the retrosternal route in this example with anastomosis in the neck.

● In transhiatal oesophagectomy, the oesophagus is ‘shelled’ out by the surgeon's hand introduced in the posterior mediastinum via the diaphragmatic hiatus and the neck without a thoracotomy. This partly blind procedure may lead to injury to mediastinal structures, such as the membranous trachea, and has also been criticised as an inadequate cancer operation.

● In experienced hands however, it is safe, and its proponents claim similar survival to the transthoracic approach. Various minimal-access methods including combinations of thoracoscopy, laparoscopy and mediastinostomy have been attempted.

● lymphadenectomy of the upper abdomen and mediastinum (two-field dissection).

● the addition of bilateral neck dissection (three-field dissection) because of the high incidence of positive cervical lymph nodes found when neck dissection is carried out (up to 30%), and better cure rate.

● The stomach is most commonly used for oesophageal substitution. In patients with previous gastric surgery, other substitutes like the colon or jejunum can be used. In cases where the substitute is brought to the neck for anastomosis, the posterior mediastinum (orthotopic), retrosternal route or subcutaneous space are alternatives.

● Tumours of the cervical oesophagus require the resection of the larynx and pharynx, and the stomach is usually used to restore continuity (pharyngo-laryngo-oesophagectomy).

● A terminal tracheostome is performed and alternative voice rehabilitation is required. For tumours limited to the postcricoid region, resection need not involve the thoracic oesophagus and a free jejunal graft can be placed in the neck to restore intestinal continuity after pharyngo-laryngectomy. For these tumours, in order to preserve the larynx, often non-operative treatment such as chemoradiation therapy is used as an alternative to surgical resection.

COMPLICATIONS

● Cardiac● Atrial arrhythmia*● Myocardial infarction● Cardiac failure● Pulmonary● Atelectesis*● Pneumothorax● Bronchopneumonia with or without aspiration*● Sputum retention*

● Pleural effusion*● Pulmonary embolism● Other medical†● Renal failure● Hepatic failure● Stroke

● Surgical● Intra-operative or post-operative haemorrhage● Tracheo-bronchial tree injury● Recurrent laryngeal nerve injury● Anastomotic leakage● Gangrene of conduit,,Intra-thoracic gastric

outlet obstruction or gastric stasis● Herniation of bowel through diaphragmatic

hiatus● Chylothorax ,Empyema,Wound infection

CHEMORADIO THERAPY NON OPERATIVE TREATMENT

● Chemoradiation therapy gives superior result to radiation alone in the treatment of oesophageal cancer, both in terms of response rate, local control, and long-term survival. Radiotherapy alone has thus mostly a palliative role in patients who cannot tolerate the addition of chemotherapy. Brachytherapy, or intraluminal radiotherapy, whereby radioactivity is delivered in close proximity to the tumour via a tube placed inside the oesophagus, can also produce good palliation.

● neo-adjuvant or adjuvant therapy with surgery.● cisplatin and flurouracil.● Placement of a prosthetic tube across the

tumour stenosis may be indicated in patients not otherwise suitable for other treatment to palliate the symptom of dysphagia. Traditional tubes placed by laparotomy (e.g. Celestin tube, Mousseau-Barbin tube) or oesophagoscopy under sedation (e.g. Atkinson tube, Souttar tube) are now rarely used since they have been superseded by a variety of self-expanding metallic stents.

● Laser therapy (Neodymium:yttrium aluminium garnet [Nd:YAG] laser) vaporises the tumour to restore luminal patency. Recannulation often requires repeated treatment sessions, and the effect is temporary.

● Other less commonlY ,injection of the tumour with alcohol or chemotherapeutic agents, photodynamic therapy, and use of a bicap heater probe. The choice of therapy depends on availability, cost and consideration of efficacy.

PROGNOSIS

Patients with squamous cell carcinomas and who undergo surgical resection alone, 5-year survival of patients with stage I 83% ,

● II 32%● III 13%● IV 7%

ADENOCARCINOMA STOMACH

● 2ND COMMONEST AND 90% OF STOMACH MALIGNANCIES.

● Gastric cancer overall has a poor prognosis in most countries with overall 5 years' survival rate being around 10%.

● Gastric cancer is generally a disease of the elderly, with average age at presentation being 70 years and a 2 to 1 male to female predominance

● The commonest site of cancers was in the antrum of the stomach.Over the past 5 decades, antral gastric cancer has become less common whereas proximal third cancers more common - to a point where proximal cancers are now the most commonly seen in most developed countries.The key identified aetiological factors for non-cardia gastric cancer are Helicobacter pylori infection(60%), high nitrite intake, low intake of fruit and vegetables, smoking and high salt intake.

TYPES ACCORDING TO PATHOGENESIS

● Two broad histological types of gastric cancer, Intestinal type cancers

● Diffuse type cancers (HEREDITARY--GENE)● (around 20–30% have a mixed picture)

CLINICAL FEATURES

Indigestion or a burning sensation (heartburn). Less than 1 in every 50 people going to a doctor with indigestion have cancer.

● Loss of appetite, especially for meat● Abdominal discomfort or irritation

Weakness and fatigue● Bloating of the stomach, usually after meals

CLINICAL FEATURES

Abdominal pain in the upper abdomen● Nausea and occasional vomiting● Diarrhea or constipation● Weight loss● Bleeding: vomiting blood or having blood in the

stool, the latter apparent as black discoloration (melena) and sometimes leading to anemia.

● Dysphagia: if extension of the gastric tumor into the esophagus.

INVESTIGATIONS● CBS (ANEMIA),LFT,● esophagogastroduodenoscopy or EGD● Double-contrast upper GI series and barium

swallows may be helpful in delineating the extent of disease when obstructive symptoms are present or when bulky proximal tumors prevent passage of the endoscope to examine the stomach distal to an obstruction (more common with gastroesophageal [GE]-junction tumors). These studies are only 75% accurate and should for the most part be used only when upper GI endoscopy is not feasible.

● CT scan or MRI of the chest, abdomen, and pelvis assess the local disease process as well as evaluate potential areas of spread (ie, enlarged lymph nodes, possible liver metastases).

● Endoscopic ultrasound allows for a more precise preoperative assessment of the tumor stage. Endoscopic sonography is becoming increasingly useful as a staging tool when the CT scan fails to find evidence of T3, T4, or metastatic disease.

STAGING● Stage 0 - Tis, N0, M0● Stage IA - T1, N0 or N1, M0● Stage IB - T1, N2, M0 or T2a/b, N0, M0● Stage II - T1, N2, M0 or T2a/b, N1, M0 or T2,

N0, M0● Stage IIIA - T2a/b, N2, M0 or T3, N1, M0 or

T4, N0, M0● Stage IIIB - T3, N2, M0● Stage IV - T1-3, N3, M0 or T4, N1-3, M0, or

any T, any N, M1

SURVIVAL RATES

● Stage 0 - Greater than 90%● Stage Ia - 60-80%● Stage Ib - 50-60%● Stage II - 30-40%● Stage IIIa - 20%● Stage IIIb - 10%● Stage IV - Less than 5%.

TREATMENT OPTIONS

● DEPENDS ON STAGE ● SURGICAL ----CURATIVE● -----PALLIATIVE

NON SURGICAL

CHEMO RADIOTHERAPY

SURGERICAL RESECTIONS

● Endoscopic mucosal resection:

Resection mucosa in Early stage Disease● Partial(stapler anastomosis ) ,Total

Gastrectomy , Laparoscopic Gastrectomy

PARTIAL GASTRECTOMY

● INDICATIONS

● Gastric neoplasia

● Recurrent ulcerations after truncal vagotomy and antrectomy

● CONTRAINDICATIONS

● Ascites (relative)

● Unless indicated for palliation, gastrectomy is not performed in the presence of:

● Peritoneal disease

● Hepatic metastases

● Diffuse nodal metastases

PARTIAL GASTRECTOMY

● INCISION:

An upper midline incision from the xiphoid process to the umbilicus with an optional extension inferior to the umbilicus provides quick and bloodless access to the abdomen.

● A thorough exploration of the abdominal cavity to look for metastasis in the liver, peritoneum, omentum, and pelvis is performed first.

● After resection of the stomach, continuity can be achieved via gastroduodenal anastomosis (Billroth I). A tension-free gastroduodenal anastomosis requires good duodenal mobilization. The second option is to close the duodenal end and to perform a gastrojejunal anastomosis (Billroth II or its modifications). Two main variations to the gastrojejunal anastomosis include an end-to-side gastrojejunostomy using an uninterrupted loop of jejunum and an end-to-side gastrojejunostomy to a Roux loop.

Duodenal mobilization:● perform a gastroduodenal anastomosis● The duodenum is mobilized by incising the

peritoneum along its lateral border and then reflecting the duodenum to the left side until the inferior vena cava is exposed. This process is also referred to as Kocherization.

● avoid injury to the structures in the lesser omentum and middle colic vessels

● Omental mobilization:● The greater omentum is freed from the

transverse colon by dividing along the avascular plane between the transverse colon and the anterior leaf of the omentum.

● injury to the middle colic artery.The posterior wall of the stomach is freed by dividing gastropancreatic folds of peritoneum.

Duodenal division● The right gastric artery is identified at the

inferior end of the lesser curvature.This is doubly ligated and divided. Similarly, the gastroepiploic artery is identified close to the inferior end of the greater curvature, doubly ligated, and divided.At this point, about 1-2 cm of duodenum adjacent to the pylorus is cleared of all fat and vascular adhesions. Care is taken to avoid injury to the pancreatic tissue while clearing the duodenum. The duodenum is divided by a linear cutter.

● Gastric division

Greater curvature of the stomach is mobilized further by dividing the gastrosplenic ligament. Depending on the extent of gastrectomy planned, the greater curvature is mobilized to the point where the gastroepiploic artery is closest to the gastric wall (hemigastrectomy) or farther proximally to the second short gastric artery (subtotal gastrectomy). The first short gastric artery is left behind to supply the remnant stomach.

The left gastric artery is divided as a part of subtotal gastrectomy. This artery divides into two branches close to the lesser curvature. The left gastric artery is secured via double ligation or ligation followed by transfixing suture on the arterial side and a tie on the gastric side before being divided.Stomach is divided with a linear cutter at the site identified for proximal resection. At this stage, the specimen is delivered out.

Lymph Node Dissection

Lymph node dissection can be categorized into D1, D2, D3, or D4 based on the lymph node stations,

● D1 lymphadenectomy: Removal of perigastric nodes (3 cm around tumor)

● D2 lymphadenectomy: Removal of nodes along the left gastric artery, common hepatic artery, celiac trunk, splenic hilus, and splenic artery

● D3 lymphadenectomy: Include dissection of lymph nodes along the hepatoduodenal ligament, posterior surface of the head of the pancreas, and the root of the mesentery (superior mesenteric vessels)

● D4 lymphadenectomy: Dissection along the para-aortic and paracolic region

● Resection of adjacent organs● Resection of adjacent organs (eg, distal

pancreas, spleen, colon) is performed for lesions with direct involvement into these structures. Distal pancreatectomy and splenectomy are not performed as part of a conventional D2 lymphadenectomy owing to increased postoperative morbidity and mortality.

ReconstructionReconstruction is performed with Billroth I or Billroth II.

Billroth I

A part of the staple line on the gastric side in the inferior aspect toward the greater curvature is opened up corresponding to the duodenal end diameter. Interrupted delayed absorbable sutures are taken from the middle of the posterior walls of the stomach and the duodenum. After all sutures are placed along the posterior layer, they are tied starting from the lesser curvature side. Once secured, the anterior layer is then similarly sutured.

● Billroth II● The duodenal stump remains closed. A loop of jejunum is

identified close to the duodenojejunal flexure.The loop is anchored to the posterior wall of the stomach with delayed absorbable seromuscular sutures. An opening is made in the jejunum equal to about twice the diameter of Anastomosis is performed with a continuous suture of absorbable suture starting from the middle of the posterior layer on either side and continued to meet in the middle of the anterior layer. A fourth layer of seromuscular sutures is placed to bury the anterior continuous suture line. The staple line on the stomach is opened to correspond to this length.

● The abdominal wound is lavaged thoroughly. A right subhepatic drain is useful in early detection of a possible duodenal stump blowout. The abdominal wound is then closed in layers.

TOTAL GASTRECTOMY● INDICATIONS● Linitis plastica● Carcinoma of the proximal (upper third)

stomach● Lymphosarcoma● Sarcomatous degeneration of multiple

leiomyomas● Complicated lymphoma of the stomach that

cannot be treated with chemotherapy plus radiotherapy

● Palliation

● CONTRAINDICATIONS● Ascites (relative)● Unless it is the only palliative option in the

presence of● Peritoneal disease● Hepatic metastases● Diffuse nodal metastases

PROCEDURE

● Stomach removed ,tissue surrounding,Regional lymph nodes are often removed during surgery (called a lymphadenectomy) because the cancer may have spread to those lymph nodes.

● Roux-en-Y anastomosis: Roux-en-Y, is a surgically created (end-to-side) anastomosis. Typically, it is between stomach and small bowel that is distal (or further down the gastrointestinal tract) from the cut end.[1]

COMPLICATIONS

● INFECTION -PERITONITIS,ABSCESS,SEPSIS

● VENOUS THROMBOEMBOLISM● HERNIA● HEMMORHAGE● ADHESION OBSTRUCTION● ANASTOMOSIS LEAK,STRICTURE,ULCER● NUTRITIONAL DEFICIENCIES

DUMPING SYNDROME

● Normally, the pyloric valve at the lower end of the stomach regulates the release of food into the bowel. When the gastric bypass patient eats a sugary food, the sugar passes rapidly into the intestine, where it gives rise to a physiological reaction called dumping syndrome. The body will flood the intestines in an attempt to dilute the sugars. An affected person may feel their heart beating rapidly and forcefully, break into a cold sweat, get a feeling of butterflies in the stomach, and may have an anxiety attack. The person usually has to lie down, and could be very uncomfortable for 30–45 minutes. Diarrhea may then follow.

CHEMOTHERAPY

● Palliatively reduce the size of the tumor, relieve symptoms of the disease and increase survival time. Some drugs used in stomach cancer treatment have included: 5-FU (fluorouracil) or its analog capecitabine, BCNU (carmustine), methyl-CCNU (semustine) and doxorubicin (Adriamycin), as well as mitomycin C, and more recently cisplatin and taxotere, often using drugs in various combinations. The relative benefits of these different drugs, alone and in combination, are unclear.[47] Clinical researchers have explored the benefits of giving chemotherapy before surgery to shrink the tumor, or as adjuvant therapy after surgery to destroy remaining cancer cells.[2] Recently, a targeted treatment called trastuzumab available.

Radiation therapy (also called radiotherapy) may also be used to treat stomach cancer, often as an adjuvant to chemotherapy and/or surgery.

PROGNOSIS

● The prognosis of stomach cancer is generally poor, due to the fact the tumour has often metastasised by the time of discovery and the fact that most people with the condition are elderly (median age is between 70 and 75 years) at presentation. The 5-year survival rate for stomach cancer is reported to be less than 10%.