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STOMACH & DUODENUM


STOMACH & DUODENUM
ANATOMY
IN ADULT LIFE, STOMACH LOCATED
T10 AND L3 VERTEBRAL SEGMENT
CAN BE DIVIDED INTO ANATOMIC
REGIONS BASED ON EXTERNAL
LANDMARKS
4 REGIONS
CARDIA
FUNDUS
CORPUS (BODY)
ANTRUM
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CARDIA% REGION
&UST DISTAL TO
THE GE &UNCTION
FUNDUS%
PORTION ABOVE
AND TO THE LEFT
OF THE GE
&UNCTION
Anatomy
CORPUS% REGION
BET'EEN FUNDUS AND
ANTRUM
MARGIN NOT DISTINCTLY
EXTERNAL, HAS ARBITRARY
BORDERS
ANTRUM% BOUNDED
DISTALLY BY THE
PYLORUS
'HICH CAN BE
APPRECIATED BY PALPATION
OF A THICKENED RING OF
SMOOTH MUSCLE
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CROSS SECTION OF STOMACH
CROSS SECTION OF STOMACH CROSS SECTION OF STOMACH
CROSS SECTION OF STOMACH
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POSITION OF THE
STOMACH VARIES
'ITH BODY HABITUS
IN GENERAL% IT IS
FIXED AT T'O
POINTS
PROXIMALLY AT THE
GE &UCTION
DISTALLY BY THE
RETROPERITONEAL
DUODENUM
Anatomy
ANTERIOR% IN CONTACT 'ITH
LEFT HEMI%DIAPHRAGM, LEFT
LOBE AND ANTERIOR SEGMENT
OF RIGHT LOBE OF THE LIVER
AND THE ANTERIOR PARIETAL
SURFACE OF THE ABDOMINAL
'ALL
POSTERIOR% LEFT DIAPHRAGM,
LEFT KIDNEY, LEFT ADRENAL
GLAND, AND NECK, TAIL AND
BODY OF PANCREAS
THE GREATER CURVATURE IS
NEAR THE TRANSVERSE COLON
AND TRANSVERSE COLON
MESENTERY
THE CONCAVITY OF THE SPLEEN
CONTACTS THE LEFT LATERAL
PORTION OF THE STOMACH
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BLOOD SUPPLY OF STOMACH
BLOOD SUPPLY OF STOMACH ARISES FROM
COELIAC AXIS
LEFT GASTRIC ARTERY
COMMON HEPATIC ARTERY
SPLENIC ARTERY
SPLENIC ARTERY GIVES
SHORT GASTRIC
LEFT GASTRO EPIPLOIC
COMMON HEPATIC ARTERY GIVES
RIGHT GASTRIC A() GASTRO DUODENAL A(
GASTRODUODENAL ARTERY GIVES RT( GASTROEPIPLOIC
ART(
VASCULATURE
VASCULATURE
'ELL VASCULARI*ED ORGAN
ARTERIAL FLO' MAINLY DERIVED FROM CELIAC ARTERY
3 BRANCHES
LEFT GASTRIC ARTERY
SUPPLIES THE CARDIA OF THE STOMACH AND DISTAL ESOPHAGUS
SPLENIC ARTERY
GIVES RISE TO + BRANCHES 'HICH HELP SUPPLY THE GREATER
CURVATURE OF THE STOMACH
LEFT GASTROEPIPLOIC
SHORT GASTRIC ARTERIES
COMMON HEPATIC OR PROPER HEPATIC ARTERY
+ MA&OR BRANCHES
RIGHT GASTRIC% SUPPLES A PORTION OF THE LESSER
CURVATURE
GASTRODUODENAL ARTERY
%GIVES RISE TO RIGHT GASTROEPIPLOIC ARTERY
%HELPS SUPPLY GREATER CURVATURE IN CON&UNCTION
'ITH LEFT GASTROEPIPLOIC ARTERY
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VENOUS DRAINAGE
PARALLELS ARTERIAL SUPPLY
LYMPHATIC DRAINAGE
LYMPH FROM THE PROXIMAL PORTION OF THE STOMACH DRAINS ALONG
THE LESSER CURVATURE FIRST DRAINS INTO SUPERIOR GASTRIC LYMPH
NODES SURROUNDING THE LEFT GASTRIC ARTERY
DISTAL PORTION OF LESSER CURVATURE DRAINS THROUGH THE
SUPRAPYLORIC NODES
PROXIMAL PORTION OF THE GREATER CURVATURE IS SUPPLIED BY THE
LYMPHATIC VESSELS THAT TRAVERSE THE PANCREATICOSPLENIC NODES
ANTRAL PORTION OF THE GREATER CURVATURE DRAINS INTO THE
SUBPYLORIC AND OMENTAL NODAL GROUPS
IN GENERAL% THE LYMPHATIC DRAINAGE OF THE HUMAN STOMACH,
LIKE ITS BLOOD SUPPLY, EXHIBITS EXTENSIVE INTRAMURAL
RAMIFICATIONS AND A NUMBER OF EXTRAMURAL COMMUNICATIONS(
THEREFORE SPREAD BEYOND IS OFTEN BEYOND REGION OF ORIGIN
AT A DISTANCE FROM THE PRIMARY LYMPHATIC *ONE
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NERVE SUPPLY
LEFT AND RIGHT VAGUS NERVES DESCEND
PARALLEL TO THE ESOPHAGUS 'ITHIN
THE THORAX BEFORE FORMING A PERI%
ESOPHAGEAL PLEXUS BET'EEN THE
TRACHEAL BIFURCATION AND THE
DIAPHRAGM
FROM THIS PLEXUS, T'O VAGAL TRUNKS
COALESCE BEFORE PASSING THROUGH
THE ESOPHAGEAL HIATUS OF THE
DIAPHRAGM
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NERVELEFT
(ANTERIOR) VAGUS
LEFT OF THE
ESOPHAGUS
BRANCHES
HEPATIC BRANCH
SUPPLIES LIVER
AND BILIARY
TRACT
ANTERIOR GASTRIC
OR ANT( NERVE OF
LATARGET

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RIGHT (POSTERIOR)
VAGUS NERVE
RIGHT OF THE
ESOPHAGUS
BRANCHES
CELIAC
POSTERIOR
LATARGET
INNERVATES
POSTERIOR
GASTRIC 'ALL
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PARASYMPATHETIC INNERVATION OF
STOMACH% VAGUS NERVE
,0- OF FIBER IN VAGAL TRUNK IS
AFFERENT (INFO TRANSMITTING FROM
STOMACH TO CNS)
SYMPATHETIC INNERVATION OF
STOMACH% SPLANCHNIC NERVE
DERIVED FROM SPINAL SEGEMENT T.%T10
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MICROSCOPIC ANATOMY
GLANDULAR PORTIONS OF STOMACH
LINED BY SIMPLE COLUMNAR EPITHELIUM
THIS LUMINAL SURFACE IS INTERRUPTED AT
INTERVALS BY GASTRIC PITS
OPENING INTO THESE GASTRIC PITS ARE ONE OR
MORE GASTRIC GLANDS THAT HAVE FUNCTIONAL
SIGNIFICANCE
MUCOSA HAS THREE TYPES OF GASTRIC GLANDS
%CARDIAC
%OXYNTIC
%ANTRAL
M/01"20"3/0 An!"#$
CARDIAC GLANDS
LOCATION% CARDIA
CONTAIN MUCOUS
FUNCTION% SECRETE
MUCOUS (PROVIDES A
PROTECTIVE COAT FOR
LINING OF STOMACH)
OXYNTIC GLANDS
MOST DISTINCTIVE
FEATURE OF THE
STOMACH
LOCATION% FUNDUS AND
CORPUS
CONTAINS MANY CELL
TYPES
M/01"20"3/0 An!"#$
PARIETAL CELLS
LOCATION% NECK OF
GASTRIC PIT
STIMULATED BY ACH,
HISTAMINE AND
GASTRIN
SECRETES HCL 4
INTRINSIC FACTOR
CHIEF CELLS
LOCATION% BASE OF
GASTRIC PIT
STIMULUS% VAGAL
SECRETES
PEPSINOGEN
(EVENTUALLY LEADS
TO PEPSIN% DIGESTIVE
EN*YME)
M/01"20"3/0 An!"#$
ANTRAL GLANDS
GASTRIN CELLS
LOCATION% MUCOSA OF DISTAL STOMACH
STIMULUS% AMINO ACIDS
SECRETION% GASTRIN (STIMULATES HCL
PRODUCTION BY 'AY OF PARIETAL CELLS)
SOMATOSTATIN
LOCATION% MUCOSA OF DISTAL STOMACH 4
DUODENUM
STIMULUS% HCL OR LO' PH IN DUODENUM
ACTIONS% INHIBITS GASTRIC EMPTYING, PANCREATIC
SECRETIONS, AND GALLBLADDER CONTRACTION
P5$2/"6"7$
THE STOMACH CONTAINS A NUMBER OF
BIOLOGICALLY ACTIVE PEPTIDES IN NERVES
AND ENDOCRINE CELLS
EX( GASTRIN, SOMATOSTATIN, VASOACTIVE
INTESTINAL PEPTIDE (VIP), SUBSTANCE P, AND
GLUCAGON, ETC
THE T'O PEPTIDES OF GREATEST IMPORTANCE
TO HUMAN DISEASE AND CLINICAL SURGERY
ARE
GASTRIN
SOMATOSTATIN
P5$2/"6"7$
GASTRIN
MOST IMPORTANT STIMULUS IS A MEAL
AMINO ACIDS THAT RESULTS FROM PROTEOLYSIS
FAT AND CARBOHYDRATES ARE NOT STIMULI FOR GASTRIN
SECRETION
GASTRIC DISTENTION THAT OCCURS FROM A MEAL 'ILL
STIMULATE CHOLINERGIC NEURONS THEREBY RELEASING
GASTRIN
GASTRIN 'ILL THEN PROMPT PARIETAL CELL TO SECRETE HCL
ONCE GASTRIC DISTENTION DIMINISHES, VIP%
CONTAINING NEURONS ARE ACTIVATED CAUSING
STIMULATION OF SOMATOSTATIN, THUS ATTENUATING
GASTRIN SECRETION
OVERALL, A LUMEN PH 83(0 'ILL POTENTIATE
GASTRIN RELEASE, 'HEREAS A PH 93(0 'ILL INHIBIT
ITS RELEASE
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BACKGROUND
Second most common cancerre!ated deat"#
$orea% &a'an% C"(na% Ta()an "(*" rates#
++%,,, d(a*nosed ann-a!!y (n US#
./
t"
most common cancer#
D(0c-!t to c-re% as ad1anced d(sease#
Most d(e o2 rec-rrent d(sease e1en a2ter resect(on 2or c-re#
C
A
R
C
I
N
O
M
A

S
T
O
M
A
C
H
D
R
#
M
#
R
A
3
I
C
H
A
N
D
R
A
%
M
#
S
ANATOMY
Stomac" 4e*(ns at 5E 6-nct(on% ends at
d-oden-m#
7 'arts -''ermost (s card(a% !ar*est
'art (n m(dd!e (s 4ody% t"e !ast 'art (s
'y!or-s#
Card(a conta(ns m-c(n 'rod-c(n* ce!!s#
F-nd-s or 4ody m-co(d ce!!s% c"(e2
ce!!s% 'ar(eta! ce!!s#
Py!or-s "as m-c(n 'rod-c(n* ce!!s#
ANATOMY
F(1e !ayers8 M-cosa%
s-4m-cosa% m-sc-!ar
!ayer% s-4serosa! !ayer%
serosa! !ayer#
Per(tone-m o2 *reater
sac co1ers anter(or
s-r2ace
A 'ort(on o2 !esser sac
dra'es 'oster(or!y o1er
stomac"#
T"e 5E 6-nct(on "as
!(m(ted serosa!
co1er(n*#
FREIUENCY
US8 se1ent" !ead(n* ca-se o2 cancer deat"s%
)(t" ++%,,, d(a*nosed year!y% and ./%,,,
deat"s#
Internat(ona!!y8 second most common cancer#
Tremendo-s *eo*ra'"(c 1ar(at(on% )(t" "(*"est
deat" rates (n C"(!e% &a'an% and 2ormer USSR#
RACE
H(*"er (n As(an co-ntr(es#
&a'anese detect 'at(ents at 1ery ear!y sta*e%
'at(ents a''ear to do 9-(te )e!!#
ETIOLOGY
D(et
H# Py!or(
Pre1(o-s stomac" s-r*ery
Pern(c(o-s anem(a
Po!y's: rare!y a 'rec-rsor;
Atro'"(c *astr(t(s
Rad(at(on% *enet(cs
DIET
Certa(n d(ets are (m'!(cated#
R(c" (n '(c<!ed 1e*eta4!es% sa!ted =s"% e>cess(1e
d(etary sa!t% smo<ed meats#
A d(et t"at (nc!-des 2r-(ts and 1e*eta4!es r(c" (n
1(tam(n C may "a1e a 'rotect(1e e?ect#
E>cess(1e amo-nts o2 n(trates are con1erted to
n(t(tes and n(troseam(ne )"(c" are 'otent(a!
carc(no*ens#
HELICOBACTER
Im'!(cated as 'rec-rsor o2 *astr(c cancer#
H# Py!or( assoc(ated )(t" atro'"(c *astr(t(s% and
'at(ents )(t" a "(story o2 'ro!on*ed *astr(t(s
"a1e a @2o!d (ncrease (n r(s<#
Part(c-!ar!y tr-e o2 t-mors o2 antr-m% 4ody% and
2-nd-s o2 stomac"% 4-t not (n card(a#
PREVIOUS SURGERY

Pe't(c -!cer s-r*ery Part(a! *astrectomy%


5astro&e6-nostomy% Py!oro'!asty

Im'!(cated as r(s< 2actor% t"e rat(ona!


4e(n* t"at 're1(o-s *astr(c s-r*ery a!ters
norma! 'H o2 stomac" as )e!! as 4(!e
reA-> *astr(t(s

Po!y's may 4e 'rema!(*nant#


GENETIC FACTORS
Poor!y -nderstood
Some 2am(!(a! a**re*at(on e>(sts
M-tat(on o2
H ras onco*ene and o1er e>'ress(on o2 cer4 BB+ *enes
APC B Fam(!(a! Po!y'os(s
PC7 s-''ressor *ene
HNPCC
SITES OF DISTRIBUTION

The sie !" he lesi!n is classi"ie#


!n basis !" relai!nshi$ ! l!ng a%is
!" s!mach&

'()*I(+21,

F-N*-.+2,

B/*0+23,

102/)-.+47,
HISTORY
Ear!y d(sease "as no sym'toms% some 'at(ents )(t"
(nc(denta! com'!a(nts *et an ear!y d(a*nos(s#
I2 sym'toms% (t reAects ad1anced d(seaseD T"ese may
(nc!-de (nd(*est(on%
na-sea%
dys'"a*(a%
ear!y sat(ety%
anore>(a%
)e(*"t !oss#
HISTORY
Late com'!(cat(ons (nc!-de8
'!e-ra! e?-s(ons%
'er(tonea! e?-s(ons%
5astr(c O-t!et O4str-ct(on%
5astro Eso'"a*ea! o4str-ct(on%
Sma!! Bo)e! O4str-ct(on%
4!eed(n*%
6a-nd(ce%
cac"e>(a#
PHYSICAL EXAMINATION
A!! '"ys(ca! s(*ns are !ate e1ents#
Too !ate 2or c-rat(1e 'roced-res#
Pa!'a4!e stomac" )(t" s-cc-ss(on s'!as"%
"e'atome*a!y%
3(rc"o) nodes%
s(ster Mary &ose'" nodes%
B!-mer s"e!2%
)e(*"t !oss%
'a!!or 2rom 4!eed(n* and anem(a#
LABORATORY

Ass(sts (n determ(n(n* o't(ma! t"era'y#

CBC (dent(=es anem(a% )(t" may 4e


ca-sed 4y 4!eed(n*% !(1er dys2-nct(on%
or 'oor n-tr(t(on#

7,E "a1e anem(a#

E!ectro!yte 'ane!s and LFTs are a!so


essent(a! to 4etter c"aracter(Fe 'at(ents
c!(n(ca! state#
IMAGING STUDIES

E5D8 sa2e% s(m'!e% 'ro1(d(n* a 'ermanent


co!or '"oto*ra'"(c record#

O4ta(ns t(ss-e 2or d(a*nos(s#

U5I8 detects !ar*e t-mors% 4-t on!y


occas(ona!!y detects e>tens(on (nto
eso'"a*-s or d-oden-m% es'ec(a!!y (2
sma!! or s-4m-cosa!#
IMAGING STUDIES
CGR8 done to e1a!-ate 2or metastases#
CT scan or MRI o2 c"est% a4domen% 'e!1(s8
e1a!-ate !oca! d(sease 'rocess% and areas o2
s'read# Some t-mors are deemed -nresecta4!e
4ased on t"e test(n*#
Acc-rate!y 'red(cts sta*e @@HHE#
Poor noda! stat-s 'red(ct(on#
ENDOSCOPIC ULTRASOUND
Endosco'(c -!traso-nd8 B;0"#/n7
;A!1;#;6$ <2;><6 2 2!7/n7 !""6, @5;n CT
>/62 !" 25"@ T3, T4, "1 #;!2!!/0 =/2;2;(
Used )(t" neoad6-1ant c"emo to strat(2y
'ts
Can ac"(e1e reso!-t(on o2 ,#. mm#
Cannot re!(a4!y d(st(n*-(s" 4et)een
t-mor and =4ros(s#
O1era!! sta*(n* acc-racy o2 HCE
Poor 2or T+ !es(ons :7IE;
Better 2or T.:I,E;% T7 :J,E;
HISTOLOGY

Adenocarc(noma JCE

Lym'"omas +E

Carc(no(ds .E

Adenocat"omas .E

S9-amo-s ce!! .E
HISTOLOGY

Adenocarc(noma (s c!ass(=ed accord(n*


to t"e most -n2a1ora4!e m(crosco'(c
e!ement 'resent8 t-4-!ar% 'a'(!!ary%
m-c(no-s% s(*netr(n* ce!!s#

A!so (dent(=ed 4y *ross a''earance8


-!cerat(1e% 'o!y'o(d% sc(rro-s% s-'er=c(a!
s'read(n*% m-!t(centr(c% or Barrett
ecto'(c#

3ar(ety o2 ot"er sc"emes8 Borrmann%


La-ren#
LAUREN SYSTEM

Ty'e I (ntest(na! *astr(c cancer%


ar(ses
(ntest(na! meta'!as(a#
2orms 'o!y'o(d t-mo-r or -!cer

Ty'e II D(?-se *astr(c cancer


(n=!tart(n* (n stomac" )a!! )(t"o-t
'rod-c(n* o41(o-s mass !es(on
MACROSCOPIC TYPES
Pro!(2erat(1e ty'e 4-!<y% ca-!(Ao)er !(<e
U!cerat(1e ty'et"e most ty'e% Mc Py!or-s antr-m re*(on to)ards
!esser c-r1at-re#
Co!!o(d or m-co(d ty'e rare 1ar(ety% mass(1e t-mor o2
*e!at(no-s a''earance# Cancer ce!!s !(ne t"e acc-m-!at(on o2 co!!o(d#
L(n(t(s '!ast(ca a!so a rare 1ar(ety#tm ce!!s (n=!trate t"e s-4
m-cosa and s-4serosa and m-sc!e coat e>tens(1e!y )(t"o-t 'rot-d(n*
(nto t"e !-men o2 t"e stomac"#
Pro!(2erat(on o2 =4ro-s t(ss-e (n t"e s-4m-cosa *(1(n* mot"er o2 'ear!
a''earance#
Loca!(sed B(n1o!1es -s-a!!y 'y!or-s re*(on
*enera!(Fed#:)"o!e stomac" (os contracted and r(*(d;
STAGING
Pr(mary t-mor
T> cannot 4e assessed
T, no e1(dence
T(s carc(noma (n s(t-% no (n1as(on o2 !am(na
T. (n1ades !am(na 'ro'r(a or s-4m-cosa
T+ (n1ades m-sc-!ar(s or s-4serosa
T7 'enetrates serosa% no ad6acent str-ct-re
T/ (n1ades ad6acent str-ct-res
REGIONAL LYMPH NODES
NG cannot 4e assessed
N, no nodes
N. mets (n .@ re*(ona! nodes
N+ mets (n H.C re*(ona! nodes
N7 mets (n more t"an .C re*(ona!
nodes
DISTANT METASTASES
MG cannot 4e assessed
M, no d(stant metastases
M.d(stant metastases
EARLY GASTRIC CANCER
5ast(c cancer con=nes to m-cosa and s-4m-cosa
(rres'ect(1e o2 Lym'" node stat-s
&APANESE CLASSIFICATION OF EARLY 5ASTRIC
CANCER
Ty'e I%II% a;%4;%c; III%
Ad1anced 5astr(c Cancer 4eyond s-4m-cosa coat
and (n1o!1es M-sc-!ar(s 'ro'r(a

BormannKs c!ass(=cat(on Ty'e I to I3


PROGNOSTIC FEATURES

De't" o2 (n1as(on t"ro-*" *astr(c


)a!!% 'resence or a4sence o2
re*(ona! !ym'" node (n1o!1ement

T"e *reater n-m4er o2 'os(t(1e


nodes% t"e *reater t"e !(<e!("ood
o2 !oca! or system(c 2a(!-re
'osto'erat(1e!y
SPREAD PATTERNS

D(rect!y% 1(a !ym'"at(cs% or


"emato*eno-s!y

D(rect e>tens(on (nto oment-m%


'ancreas% d(a'"ra*m% trans1erse co!on%
and d-oden-m#

I2 !es(on e>tends 4eyond )a!! to a 2ree


'er(tonea! s-r2ace% 'er(tonea!
(n1o!1ement (s 2re9-ent#
SPREAD PATTERNS

T"e 1(s(4!e *ross !es(on 2re9-ent!y


-nderest(mates tr-e e>tent#

A4-ndant !ym'"at(c c"anne!s (n


s-4m-cosa! and s-4serosa! !ayers a!!o)
2or easy s'read#

T"e s-4m-cosa! '!e>-s (s 'rom(nent (n


eso'"a*-s% t"e s-4serosa! '!e>-s
'rom(nent (n d-oden-m% )"(c" a!!o)s
2or 'ro>(ma! and d(sta! s'read#

L(1er mets common% 2rom


"emato*eno-s s'read#
LAPAROSCOPY
Ins'ect 'er(tonea! s-r2aces% !(1er s-r2ace#
Ident(=cat(on o2 ad1anced d(sease a1o(ds non
t"era'e-t(c !a'arotomy (n +CE#
Pat(ents )(t" sma!! 1o!-me metastases (n
'er(tone-m or !(1er "a1e a !(2e e>'ectancy o2 7
J mont"s% t"-s rare!y 4ene=t 2rom 'a!!(at(1e
resect(on#
LYMPH NODE DISSECTION
A&CC8 n-m4er rat"er t"an !ocat(on o2 LN (s
'ro*nost(c#
E>tent o2 d(ssect(on contro1ers(a!#
Noda! (n1o!1ement (nd(cates 'oor 'ro*nos(s%
and more a**ress(1e a''roac"es to remo1e
t"em are ta<(n* 2a1or#
On*o(n* tr(a!s re*ard(n* t"(s (n E-ro'e#
Cr(t(cs ar*-e t"at t"e a''arent 4ene=t
assoc(ated )(t" e>tended LND reAects sta*e
m(*rat(on :eac" LN (s re1(e)ed more care2-!!y;#
RESIDUAL DISEASE R STATUS

T-mor stat-s 2o!!o)(n* resect(on#

Ass(*ned 4ased on 'at"o!o*y o2


mar*(ns#

R, no res(d-a! *ross or m(crosco'(c


d(sease#

R. m(crosco'(c d(sease on!y#

R+ *ross res(d-a! d(sease#

Lon* term s-r1(1a! on!y (n R, resect(on#


JDK NOMENCLATURE

Descr(4es e>tent o2 resect(on and


!ym'"adenectomy#

D. remo1es a!! nodes )(t"(n 7cm o2


t-mor#

D+ D. '!-s "e'at(c% s'!en(c% ce!(ac% and


!e2t *astr(c nodes#

D7 D+ '!-s omentectomy% s'!enectomy%


d(sta! 'ancreatectomy% c!earance o2
'orta "e'at(s nodes#

C-rrent standards (nc!-de a D.


d(ssect(on on!y#
TYPE OF SURGERY

TOTAL 5ASTRECTOMY : (2 re9-(red


2or ne*at(1e mar*(ns;%

ESOPHA5O5ASTRECTOMY 2or t-mors


o2 t"e card(a and 5E 6-nct(on%

SUBTOTAL 5ASTRECTOMY 2or t-mors


o2 t"e d(sta! stomac"#

E>tens(1e !ym'"at(cs re9-(re Ccm


mar*(n#
OUTCOME

Cyear s-r1(1a! 2or a c-rat(1e resect(on


(s 7,C,E 2or sta*e II d(sease% .,+CE
2or sta*e III d(sease#

Ad6-1ant t"era'y 4eca-se o2 "(*"


(nc(dence o2 !oca! and system(c 2a(!-re#
COMPLICATIONS
Morta!(ty .+E
Anastamot(c !ea<%

4!eed(n*% (!e-s%
trans(t 2a(!-re%
c"o!ecyst(t(s%
'ancreat(t(s%

'-!monary
(n2ect(ons% and
t"rom4oem4o!(sm#
Late
com'!(cat(ons
(nc!-de d-m'(n*
syndrome%
1(tam(n B.+
de=c(ency% reA->
eso'"a*(t(s%
osteo'oros(s#
AD&UVANT THERAPY

Rat(ona!e (s to 'ro1(de add(t(ona! !oco


re*(ona! contro!#

Rad(ot"era'y st-d(es s"o) (m'ro1ed


s-r1(1a!% !o)er rates o2 !oca! rec-rrence
)"en com'ared to s-r*ery a!one#

In -nresecta4!e 'at(ents% "(*"er / year


s-r1(1a! )(t" m-t(moda! t>% (n
com'ar(son to c"emo a!one#
CHEMOTHERAPY

N-mero-s random(Fed c!(n(ca! tr(a!s


com'ar(n* com4(nat(on c"emot"era'y
(n t"e ad6-1ant sett(n* to s-r*ery
a!one d(d not demonstrate a cons(stent
s-r1(1a! 4ene=t#

T"e most )(de!y -sed re*(men (s CFU%


do>or-4(c(n% and m(tomyc(nc# T"e
add(t(on o2 !e-<o1or(n d(d not (ncrease
res'onse rates#
ADVANCED UNRESECTABLE DISEASE

S-r*ery (s 2or 'a!!(at(on% 'a(n% a!!o)(n*


ora! (nta<e

Rad(at(on 'ro1(des re!(e2 2rom 4!eed(n*%


o4str-ct(on and 'a(n (n C,HCE# Med(an
d-rat(on o2 'a!!(at(on (s /.I mont"s
TUMOUR MARKERS
CEA
CA .JJ
CA C,
CA .+C
CA H+/ MOST IMPORTANT
T
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