CPC

Faiza Hashim Soomro

PG- Gen Surgery
 Profile
MR No: 19-15-00-63
Age: 57 years Gender: Male
Address: Islamabad
Date of admission: 31-01-2019
Source of admission: Opd

Chief Complaint:
 Shortness of breath - 3 months
 Pallor – 04 months
 History of present illness
 Shortness of breath
• Dyspnea on exertion, denies orthopnea and sleep
apnea
• No history of chest pain
 Pallor
• No history of bleeding (bleeding P/R, haemetemesis,
melena, hemoptysis, bleeding gums, )
• No history of bleeding diasthesis
• No histroy of worm infestation
 No history of weight loss
 No h/o abd pain, jaundice, fever, vomiting,
tenesmus
 No history of altered bowel habits
 Past History
› No comorbids
› No history of surgery
 Personal History
› Ex-smoker, No addiction
› Govt employee
 Family history
› Father diabetic, hypertensive
 Allergy
› NKDA, NKFA
 Medication
› No regular medication
 Examination
• General Physical Examination
– Middle aged male patient, lying comfortably in
bed
– Pallor +ve
– No clubbing, cyanosis, koilonychia
– No jaundice, edema
• Vitals
– BP: 110/70 mmHg
– Pulse: 82 b/m
– Temp: Afebrile
– RR: 15
 Systemic Exam
• CVS
– S1, S2 audible
– No added sound
• CNS
– Conscious, well oriented
• Resp
– Normal vesicular breathing
• GIT
– Soft, non-tender
– No visceromegaly
– BS +ve
• DRE + Proctoscopy
– No hemorrhoids, fissure or fistula
– Anal sphincter tone was normal
– Anal mucosa looked normal
Differentials ???
 Differntial Diagnosis?
• Right sided CA colon
• CA stomach
• Peptic Ulcer Disease
 CT SCAN:
• Stomach was partially distended and
thickening of stomach wall was noted
involving region of pylorus and
gastroduodenal junction measuring 14mm.
However, rest of duodenum was normal.
• Liver, mesentery, gall bladder, spleen,
pancreas and both kidneys were
unremarkable. No ascites.
• Prostate was enlarged measuring 4.8x5.9x4.4
cm
 Upper GI endoscopy
• Circumferential growth noted in pyloric
opening
• 10mm scope couldn’t pass so 5mm
choledochoscope negotiated and D1 & D2
was found normal
• Scoped again with 10mm scope for
biopsies.
 Biopsy:

•Poorly differentiated Adencarcinoma

•CK positive
 Surgery
• Laparoscopic Subtotal Gastrectomy with
Roux-En-Y GastroJejunostomy was planned.
• Informed consent
• Anesthesia consultation
• CBC, U & E, RBS, PT, Hep B & C screening
• 2 PRBCs arranged
• NPO mid-night
• Prophylactic Antibiotic at the time of incision.
 Surgery

• GA given with ET tube

• French Position
• NG & Foley’s passed
• Abdomen was prepped & draped
Patient position
 Trocar position
– Supra- umbilical 10mm
trocar- telescope
– Left Sided 5mm port in
anterior axillary line –
dissection
– Left sided 10mm port in
mid-clavicular line– for
dissection
– Right sided mid clavicular
line- for use of stapling
device & dissection
 OPERATIVE STEPS:
• DIAGNOSTIC LAPROSCOPY PERFORMED
• TUMOR LOCATED
• LIVER RETRACTED VIA NETHENSON
• STOMACH WAS MOBILIZED
• DIVISION OF THE STOMACH
• DIVISION OF THE GREATER OMENTUM
• CREATION OF GASTRO-JEJUNOSTOMY
• FORMATION OF ROUX LOOP AND JEJENO-
JEJUNOSTOMY
 OPERATIVE FINDINGS:
• Tumor of around 4x4cm at the pylorus.
• No ascites
• No mets in liver
• No peritoneal deposits
• No omental nodules
 Postoperative course
• No NGT
• Mobilized out of bed in evening
• Oral sips on 2nd PoD
• Clear liquids on 3rd PoD,
• No post op complications
• Discharged on 3rd poD
 HISTOPATHOLOGY REPORT
• MASS PYLORUS- ADENOCARCINOMA DIFFUSE
TYPE
– HISTOLOGIC TYPE: POORLY DIFFERENTIATED
ADENOCARCINOMA
– TUMOR SIZE: 4.0X3.9X2.5 cm
– MARGINS ARE FREE OF TUMOR
– PERINEURAL INVASION PRESENT
– TUMOR INVADES SEROSA (VISCERAL PERITONEUM)
– 6/19 LYMPH NODES INVOLVED
– PATHOLOGIC STAGING: T4aN2
 GASTRIC CARCINOMA:
• Adenocarcinoma 95%
• Lymphoma 4%
• GIST 1%
• Carcinoid, Angiosarcoma, Carcinosarcoma,
Squamous Cell Carcinoma
• Metastases from melanoma, breast
• Direct invasion from colonic or pancreatic
cancer or by peritoneal seeding as in ovary
 Epidemiology
• Fourth most common cancer
• 2nd most common cause of cancer related
deaths
• Blacks: Whites 2:1
 Etiology and risk factors
• Family history • Blood group A
• Familial polyposis • Pernicious anemia
• Gastric adenomas • Diet ( high in salt,
• HNPCC nitrates)
• H.pylori infection • Tobacco use
– Atrophic gastritis,
metaplasia
• Previous gastrectomy
• Menetrier’s disease
• EBV
Gross Morphology
• Type 1:
Polypoid

• Type 2:
Fungating

• Type 3:
Ulcerative

• Type 4:
Scirrhous
 Histological classification
• Lauren Classification:
– Intestinal type 53%
– Diffuse type 33%
– Unclassified 14%
• The Ming Classification:
– Expanding 67%
– Infiltrative 33%

• Recently HER2 overexpression has been found in

13-30% cases of breast cancer
Pathological staging
 Clinical manifestations
• Weight loss
• Early satiety and anorexia
• Abdominal pain
• Nausea vomiting bloating
• Acute GI bleeding
• Chronic occult blood loss
• Dysphagia
 Diagnostic Evaluation
• Endoscopy + Biopsy ( Gold Standard)
• Double contrast barium enema
• Abdomino-pelvic CT Scanning for staging
• EUS for differentiating T1 from advanced
disease
• PET CT
• Staging laparoscopy and Peritoneal biopsy
 Treatment
• Surgical resection is the only curative
treatment

• Exception:
– Cannot tolerate operation
– Gross peritoneal disease
 Goal
• R0 resection
• Adequate lymphadenectomy (minimum 15
lymph nodes)
• Negative margin of at least 5 cm required
• In diffuse variety, beyond 5 cm desirable
• Frozen section confirmation for clear margins
 Subtotal Gastrectomy
• Considered the standard procedure for distal and
middle gastric cancers

• ligation of the left and right gastric and gastroepiploic

arteries at origin
• En bloc removal of the distal 75% of the stomach, 2cm
of duodenum, the greater and lesser omentum,
associated lymphatic tissue
• Reconstruction
– Bilroth I gastroduodenostomy
– Billroth II gastrojejunostomy
– Roux n Y gastrojejunostomy
• operative mortality - 2 to 5%
Subtotal Gastrectomy
Bilroth I & II
 Total Gastrectomy

• with Roux-en-Y esophagojejunostomy

• In proximal gastric adenocarcinoma
 Extent of Lymph node dissection
• Subtotal gastrectomy
– D1 lymphadenectomy:
stations 1, 3-7
– D2 lymphadenectomy:
stations 8,9,11,12
• Total gastrectomy
– D1 lymphadenectomy:
stations 1-7
– D2 lymphadenectomy:
stations 8-12
Comparison of D1 &D2
lymphadenectomy
 Treatment options for early gastric
cancer
• Endoscopic Mucosal resection EMR
• Endoscopic Submucosal Dissection ESD
Long-Term Clinical Efficacy and Perioperative Safety of
Endoscopic Submucosal Dissection versus Endoscopic
Mucosal Resection for Early Gastric Cancer: An Updated
Meta-Analysis.
Zhao Y1, Wang C1.
Abstract
To systematically evaluate the safety and efficacy of endoscopic submucosal dissection (ESD)
versus endoscopic mucosal resection (EMR) for early gastric cancer (EGC).
METHODS:
We searched the databases of PubMed, Web of Science, EMBASE, and the Cochrane Library from
January 2000 to April 2017 and included studies that compared the outcomes of ESD with EMR for EGC.
These eligible studies that met the inclusion criteria were screened out and were assessed by two
independent investigators.
RESULT:
In total, 18 retrospective cohort studies were eligible for analysis. Our results indicated that ESD is
more beneficial than EMR in increasing the complete resection rate and en bloc resection rate and
decreasing the local recurrence rate. However, ESD prolonged operative time and increased incidence
of gastric perforation than EMR. No differences were found in postoperative bleeding rate between the
two approaches.
CONCLUSION:
Compared with EMR, ESD offers higher complete resection rate, higher en bloc resection rate, and
lower local recurrence rate but has prolonged operative time and increased incidence
of gastric perfusion. There is no statistical difference in the rate of postoperative bleeding between the
two groups. However, the above conclusion needs further verification by well-designed, randomized trials
with larger samples and long follow-up periods.
 Radiotherapy
• Role is controversial
• Number of radiosensitive tissues in the region
of the gastric bed - limits the dose
• Role in the palliative treatment of painful
bony metastases
 Chemotherapy
• Improves the outcome
• Currently used regime
– Epirubicin,
– Cis-platinum
– Infusional 5-Fluorouracil (5-FU) or an oral analogue
such as Capecitabine
• In inoperable disease
– Oxaliplatin substituted for Cis-platinum (fewer side-
effects)
• Chemotherapy in advanced disease is palliative
Zhonghua Wei Chang Wai Ke Za Zhi. 2018 Feb 25;21(2):160-164.
[Updates and interpretation on NCCN clinical practice guidelines for
gastric cancer 2017 version 5].
Qiu H1, Zhou Z2.
Abstract
The National Comprehensive Cancer Network (NCCN) issued the clinical practice guidelines for gastric
cancer 2017 edition version 5, which has been fully updated for the treatment of gastric cancer, including
systematic treatment, surgery and radiotherapy. This article review and summarize the updated NCCN
clinical practice guidelines for gastric cancer in 2017 and try to interpret it.
(1)Biomarkers: mismatch repair defect (dMMR) or high microsatellite instability (MSI-H), programmed
death ligand 1 (PD-L1) and tumor Epstein Barr virus (EBV) status should be considered for patients with
gastric cancer.
(2)Treatment of advanced gastric cancer: the major update is the application of immunotherapy
(Pembrolizumab, Nivolumab combined with Ipilimumab).
(3)Adjuvant therapy after D2 resection and perioperative treatment: the guidelines recommended
Capecitabine combined with Oxaliplatin as adjuvant therapy after radical operation, updated from
category 2A to 1; although the 2017 edition of the NCCN guidelines have not yet been adopted,
Docetaxel-based FLOT scheme has certain potential in adjuvant therapy for gastric cancer.
(4) Radiotherapy: a more detailed definition of radiotherapy for gastric cancer in different locations,
especially in high-risk lymphatic drainage areas, was updated.
(5) Genetic risk assessment: the guidelines recommended genetic screening for gastric cancer, including
hereditary diffuse gastric cancer (HDGC), Lynch syndrome, juvenile polyposis (JPS), Peutz-Jephers
syndrome (PJS) and familial adenomatous polyposis (FAP). The NCCN guidelines continue to update
based on new evidences, which is the embodiment of precision medicine in the treatment of gastric
cancer. The biggest change in the 2017 gastric cancer guidelines is the updates of immunotherapy,
which also suggests that the direction of the gastric cancer treatment began to turn to immunotherapy.
 Prognosis
• 5 years survival for gastric adenocarcinoma is
increased from 15% to 25%
• Prognostic factors:
– Lymph node involvement
– Depth of tumor invasion
– Tumor grade
– HER 2 expression
THANK YOU