SURGERY FOR GASTRIC CA

PURNENDU MUKHERJEE

SURGERY FOR GASTRIC CACURATIVEEMR(Endoscopic Mucosal

Resection)ESD(Endoscopic Submucosal

Dissection)Gastrectomy:• Total gastrectomy• Subtotal gastrectomy

PALLIATIVEAnterior GJ for carcinoma of

pyloric antrum(obstruction).Gastrectomy to combat

bleeding.

CURATIVE SURGERY:It is not possible when there is -

• Metastatic disease - haematogenous or nodal (N3)• and tumours(involvement of serosa or subserosa tissue)

ENDOSCOPIC MUCOSAL RESECTIONIndications:• T1a tumours(Early Gastric Carcinoma)• No tumours• Size<2cm• Differentiated adenocarcinoma• No endoscopic findings of ulceration

Excised with 1 cm margin up to muscularis propria.

ENDOSCOPIC SUBMUCOSAL DISSECTIONExtended indications of EMR• Size > 2 cm• Non intestinal in type

GASTRECTOMYSubtotal radical gastrectomy: Antral growth.Total radical gastrectomy: Body, fundus growth.

Oncology Clearance• Proximal clearance: 5 cm from growth• Distal clearance: Up to gastroduodenal junction

Subtotal gastrectomy—about 80 percent of distal stomach removed—done for cancers.Partial gastrectomy—about 60–75 percent stomach removed distally—done for benign conditions.

SUBTOTAL GASTRECTOMYStructures removed-• Entire greater and lesser omentum and the superior layer of

transverse mesocolon• Distal stomach along with the growth, proximal clearance of 6 cm

proximal to the growth and distal line of resection taking up to 2 cm of proximal duodenum

• D1/D2/D3 resection depending upon LN involvement

LYMPH NODE DISSECTIONDepending on extent of lymph node dissection,the gastric surgery can

be classified as D1,D2 and D3 resection.

D resection exceeds the nodal involvement by one level-• N0 – D1 resection is curative.• N1 – D2 resection is curative.• N2 – D3 resection is curative.

LYMPH NODE DISSECTIOND1 resection – removal of perigastric lymph nodes within 3 cm of

tumour(station 1 to 6)D2 resection – D1+removal of second tier of lymph nodes along main

arterial trunk(station 7 to 11),i.e., hepatic and splenic arteries etc.D3 resection – D2+removal of third tier of nodes,i.e., para aortic

nodes etc.

Now it is recommended that at least 15 lymph nodes to be removed for adequate staging. To achieve this, a D2 dissection should be the standard of care.

REGIONAL LYMPH NODES• No. 1 Right paracardial LN• No. 2 Left paracardial LN• No. 3 LN along the lesser curvature• No. 4sa LN along the short gastric vessels• No. 4sb LN along the left gastroepiploic vessels• No. 4d LN along the right gastroepiploic vessels• No. 5 Suprapyloric LN• No. 6 Infrapyloric LN

REGIONAL LYMPH NODES• No. 7 LN along the left gastric artery• No. 8a LN along the common hepatic artery (Anterosuperior group)• No. 8p LN along the common hepatic artery (Posterior group)• No. 9 LN around the celiac artery• No. 10 LN at the splenic hilum• No. 11p LN along the proximal splenic artery• No. 11d LN along the distal splenic artery• No. 12a LN in the hepatoduodenal ligament (along the hepatic artery)

REGIONAL LYMPH NODES• No. 12b LN in the hepatoduodenal ligament (along the bile duct)• No. 12p LN in the hepatoduodenal ligament (behind the portal vein)• No. 13 LN on the posterior surface of the pancreatic head• No. 14v LN along the superior mesenteric vein• No. 14a LN along the superior mesenteric artery• No. 15 LN along the middle colic vessels• No. 16a1 LN in the aortic hiatus• No. 16a2 LN around the abdominal aorta (from the upper margin of

the celiac trunk to the lower margin of the left renal vein)

REGIONAL LYMPH NODES• No. 16b1 LN around the abdominal aorta (from the lower margin of

the left renal vein to the upper margin of the inferior mesenteric artery)• No. 16b2 LN around the abdominal aorta (from the upper margin of

the inferior mesenteric artery to the aortic bifurcation)• No. 17 LN on the anterior surface of the pancreatic head• No. 18 LN along the inferior margin of the pancreas• No. 19 Infradiaphragmatic LN• No. 20 LN in the oesophageal hiatus of the diaphragm• No. 110 Paraesophageal LN in the lower thorax• No. 111 Supradiaphragmatic LN• No. 112 Posterior mediastinal LN

SUBTOTAL GASTRECTOMYRECONSTRUCTION PROCEDURES AFTER SUBTOTAL GASTRECTOMY

• Bill Roth IGastroduodenal anastomosisMobilization of 1st part of duodenum (Kocherisation)Only advantage is maintenance of anatomical continuity.

• Bill Roth IIGastrojejunal anastomosis (anterior to transverse colon)Close the proximal stump.End-to-side anastomosis.Adverse effect: Hypocalcaemia because calcium in diet is absorbed in the 1st part of duodenum and

food is by passed.Disadvantage: Bile reflux gastritis, stump carcinoma.

SUBTOTAL GASTRECTOMY

TOTAL GASTRECTOMYReconstructive Procedures after Total Gastrectomy by Roux-en-Y loop

– Y loop—afferent loop(receives bile) should be small– Roux loop(receives food) should be long(40-60 cm) to avoid bile reflux.

Advantages:– No Bile reflux– No food reflux.

Y loop

Roux loop

PALLIATIVE SURGERYPalliative procedures are done to relieve outlet obstructive symptoms or in cases of bleeding from lesionsI. Pyloric end:Tanner’s anterior gastrojejunostomy (GJ)Anterior GJ is preferred to posterior because:1. Easier to do and redo the surgery.2. Posteriorly, if done, nodes when get enlarged may compress the jejunum.3. If we want to do posterior GJ, we have to open the transverse mesocolon;thereby connecting supra-and infracolic compartments, hence transperitoneal spread becomes easier.

PALLIATIVE SURGERYII. Cardiac end1. Stent can be kept2. Laser luminization3. Souttar’s tube

III. Ultimately inoperable:Linitis plastica—feeding jejunostomy

SUMMARY1.Ultimately inoperable tumors: Feeding jejunostomy2. Inoperable tumors in: Cardiac end: Souttar’s tube; stent;laser luminisation. Pylorus end—Tanner’s anterior GJ.3. Growth in pyloric and antrum: Subtotal radical gastrectomy with Bill Roth II4. Growth in Cardiac end: Total gastrectomy with Roux-en-Y loop reconstruction5. Distant mets: Chemotherapy only.

R-RESECTIONTumour status after resecton is described by the term ‘R status’• R0 - margin –ve,both macroscopic and microscopic• R1 - margin –ve macroscopic,but microscopicaly margin +ve• R2 - margin +ve both macroscopic and microscopically

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