GASTRIC Kakha Gujabidze

ADENOCARCINOMA
INCIDENCE AND EPIDEMIOLOGY
RISK FACTORS

•Male Gender,Atrophic Gastritis,Menetriere’s disease,H.pylori

•Regional Variation – Distal (Asia) ; Proximal (Non-Asian
countries)
Distal (Asia) - associated with H. pylori,alcohol use, high-salt
diet, processed meat and low fruit and vegetable intake
Proximal – Obesity,GERD
CLINICAL & HISTOLOGIC
CLASSIFICATION
oUlcerative - MC
oPolypoid - Intraluminal
oScirrhous – Pre Linitis Plastica
oSuperficial – Intraluminal
oBorrmann – 1926 - oldest
LAUREN CLASSIFICATION
Intestinal Diffuse

Well Poorly
Differentiated Differentiated

Enviromental Familia

Gland Signet-ring

Transmural
Hemat.Spread lymphatic
Spread

Gastric Blood Type A

Atrophy
CLINICAL PRESENTATION &
EVALUATION
• Depends on Stage
• Symptoms – Vague Epigastric Pain , Weight Loss , Dysphagia,
Hematemesis , Vomiting
• PE focuses on advanced disease signs
• Cervical,Supraclavicular (Virchow) and Axillary (Irish)
Nodes,Palpable Umbilical Metastasis(SJN),Rectal shelf of
Blumer
• Upper Endoscopy to characterize location & extent
• Endoscopic Ultrasound – Depth
• Laparoscopy – Intra-abdominal Spread
CLINICAL PRESENTATION AND
EVALUATION
STAGING & RISK ASSESMENT
MANAGEMENT
MANAGEMENT OF LOCOREGIONAL
DISEASE
• Depends of Stage
• T1a – well differentiated , confined to mucosa , <2cm –
EMR / ESD
• T1 – Surgery with D1 +
• IB – III - Radical Gastrectomy -- ( Subtotal if 5 cm achieved
between GE and Tumor )
MANAGEMENT OF LOCOREGIONAL
DISEASE - LN
• D1 – Perigastric LNs
• D2 – Perigastric + those along the left gastric, common
hepatic and splenic arteries and the coeliac axis
• Current trend towards D2
• Laparoscopy – D2 problem
SPECIFIC SITUATIONS
• Metastasectomy
• Peritoneal Metastases
• Signet-cell Tumours
GASTRIC RESECTION
• Vagal Innervation
• Principles of Reconstruction
• Stapling & Hand-Suturing
• Complications
 TYPES
 Antrectomy / Hemigastrectomy – 35-50 % - Vagotomy to be
performed – Midline Incision
 Partial
 Subtotal - Lower third
 Nearly Total
 Radical - Upper third
 OVERVIEW OF APPROACH

• Midline Incision
• Liver retraction to show GE
• Omentum Excision
• Ligation of vessels ( Short gastric – difficult to reach –
potential source of blood loss + left gastric)
RECONSTRUCTION
BILLROTH I
• Pros – Preservation of normal anatomy and function digestive
system
- Easier to Perform
- less dumping and afferent loop
• Cons – Need to mobilize duodenum
- No cancer usage

Angle of Sorrow
BILLROTH II
• Pro – Low Tension anastomosis
• Cons – Dumping, Afferent loop , ulcer susceptible
• Retro
 ROUX EN Y
• pros - fewer problems with efferent/afferent limb obstruction
• cons - erosive ulcer formation still occurs.