G.

SURG NOTES

1st Final Lec

By: Ola Reda, Rawan Hamed, Reem Elnagar, Mai Mohamed,
Abdelrahman Ahmed, Mohamed Ashraf, Ibrahim Elgendy.

This is students' effort, NOT an official source.

 GASTRIC LYMPHOMA
Epidemiology :
-Common but GIST is more common.
-Stomach is the commonest site for GIT lymphomas. “NOT all body
lymphomas” accounting for 20% of extranodal NHL.
[15% of gastric CA , 2% of body lymphomas]
[ 1ry gastric lymphoma is uncommon]

Clinically:
- Vague symptoms.
•Epigastric pain
“D.D : Gastritis: pain is not severe as lymphomas”
•Early satiety leading to loss of weight •Fatigue
•Bleeding is uncommon. [but anemia is present in 50% of patients
“Not constant sign” —> alarm sign]
-Old age (6th & 7th decades) , Male > Female (2:1).
- Antrum of stomach is the commonest site.

Pathology:
-Has multiple classification systems thus has No ideal ttt‫ج‬.
-Diffuse B-cell lymphomas is the most common type —> 55%
“usually primary”
-MALT —> 40%, H. Pylori associated “if lymphoma was only
mucosal, it will regress after ttt of H. pylori”
- Burkett lymphoma —> younger age, at body of stomach & EBV
associated.
- Mantel cell
 GASTRIC LYMPHOMA
Management:
- PET scan is investigation of choice for staging.
A. Early stage : Multimodality:
According to extensions
(Metastasis)

Localized Extra gastric

(isolated lymphoma) lymphoma

Surgery Chemotherapy
NB: low immunity leads to Ex: cyclophosphamide
↑↑↑ mortality. NB: 5% risk of perforation (lesion melt)
leads to ↑↑↑ mortality

-Complications if less than 1% risk are not counselled to the patient

but higher than 1% are mentioned.
-Radiations: limited for large tumors.
Have cumulative effects (so patients affected by radiations are
more prone to showing side effects with time eg; endarteritis
obliterans), risk of complications is 30% at 10 years; d.t changes in
tissue among years.
-Surgery usually fails peripherally while Radio. fails centrally.
- 5years survival:
o 3 mod. (sx/chemo/rad) : 82% o 2 mod. (chemo/rad) : 84%

B. Late stage :
- Not amenable to sx/chemo.
- Low grade MALT: H. pylori ttt eradicated by 75% “repeated
endoscopy after 2 months to detect recurrence or reinfection”
 GASTRIC SARCOMA
-3% 0f gastric cancers.
-Arises from Mesenchymal cells.
-GIST is the most common (stomach 60-70%).
- Age : After 4th decade. “But also seen in younger”

GIST “GI Stromal Tumors" pathology:

-Submucosal tumor, slowly growing and arises from interstitial
cell of Cajal “pacemaker, at fundus of stomach ,that propagate
caudally till rectum”
-Can affect all GIT but 50% will be found in stomach.
- It’s a mass hump with ulcer that can make the patient bleed.
-Characteristic by: Association with mutation in tyrosin kinase C
kit oncogenes; so it has +ve tumor marker for express kit protein
(CD 117, stem cell factor receptor) & CD34.
- No current system for staging
- If> 2 cm considered Malignant

- Clinically: Male = Female .. presented by:

•Abdominal mass.
•GIT Bleeding with Dyspepsia if there is ulceration in mucosa.
•It may be asymptomatic and discovered accidentally by
endoscopy.
•Role Of Endoscope: 1st diagnostic in bleeding.
1- Showing normal mucosa (in this case biopsy will be difficult to
take )
2-Or if the tumor Ulcerate the overlaying mucosa (biopsy will be
helpful).
•CT is best investigation + Angiography “appears bright”
•Double contrast (barium) has limited role.
 GASTRIC SARCOMA
Management: Prognosis depends on:
1-Size 2-Mitoitic count 3-Metastasis.
Mainly surgical :
1.Remove tumor block ; no need for safety margin
2. Avoid rupture of tumor; to prevent peritoneal seeding
Leading to recurrence —> death
3. No need for lymph nodes removal ; lymphatic
metastasis is rare.
•Most recurrence is within 2 years “ up to 90% of
recurrence”.
after 5years mostly consider as new disease.
•5 years survival is : 48% “Not good as it is local tumor"

Adjuvant treatment:
•Radiation has NO benefit “radio-resistance”
•Glivic Gleevec (imatinib) : "tyrosin kinase antagonist"
(54% to 90%) —> partial response
but it is the best treatment used for now.
Target the CD117+ CD34 cells cause regression of the
tumor “used for 3-5 years; according to size of tumor”

N.B : Adenocarcinoma is Radio-resistant, while squamous

cell carcinoma is characterized by moderate
radiosensitivity. "May be"

 OBESITY SURGERY
- Effect of obesity on the body is worse than smoking.
- Obesity is a chronic disease.
- It causes early morbidity, mortality & social
disadvantages.
-70% of obese patients make social changes after losing
weight.
- Prevalence in Mediterranean : Males 16% , Females
30%.

BMI= weight / length ^2

- 20 - 25 : Normal
- >25 : overweight
- >30 : obese
•30-35 : class 1
•35-40 : class 2
- >40 : morbid obese “class 3”
- >50 : super obese

 OBESITY SURGERY
Defining weight loss:
Excess weight loss = (weight loss / excess weight) x
100%
-EWL% is 60-70% at 1st year after surgery
-Excess weight = current weight – normal weight (BMI<
25)
Causes :
1.Hereditary
2.Altered metabolism (1% hormonal effect)
3.Prescript medication
4.Obesogenic environment : Overeating & lack of exercise
(number 1 cause)
Consequences of obesity :
- Direct : “related to treatments” for associated
diseases (DM , HTN , ...etc)
- Indirect : “related to society” loss of productivity
- Mortality risk: higher after BMI > 30
Health effects of obesity :
- Diabetes type 2 (70-80%)
- Hyper-estrogenemia “predisposing factor for cancer”
- Arthritis (irreversible damage)
- Hypertension
-Social dysfunction
 OBESITY SURGERY
Treatment:

A.Non-surgical treatment:
“Little chance in morbid obesity (5%) ”

- Behavior: Eating disorders.

- Dieting (high proteins & fibers , low fat)

- Drugs :
1- Merida: decrease appetite

2- Saxenda: GLP-1 agonist

3- FDA .. Orlistat:
Inhibit absorption of fat from intestine
(30%).
Complications: diarrhea , fecal
incontinence (soil underwear).

 OBESITY SURGERY
Treatment:

B. Surgical treatment:

Indication of surgery:
1. BMI > 40 (class 3)
2. BMI > 35 (class 2) when medical
therapy has failed and comorbid
condition exist.

- Reduction intake :
•Intra-gastric balloon
•VBG “Vertical Banded Gastroplasty /
stomach stapling”
•LABG “Laparoscopic adjustable gastric
banding” .. Not done d.t its complications
(out of practice).

 OBESITY SURGERY
Treatment:

B. Surgical treatment:

- Reduction absorption:
•GBP “Gastric bypass surgery”
•BPD “Bilio-pancreatic Diversion”
•JIBP .. “ Historical” —> complications: liver
cirrhosis, not done any more

- Sleeve gastrectomy :
Removal of greater curvature, it interferes
with gastric hormones “Not absorption”
especially Hunger hormone: Ghrelin