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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_901_Библиотеки_им_академика_М_И_Перельмана
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6 Stomach
Mucosa-associated lymphoid tissue (MALT)
Presentation Epigastric pain, anorexia, weight loss, nausea and vomiting, occult
gastrointestinal bleeding, systemic B symptoms (fever, night sweats)
Contrast-enhanced CT scan of the chest, abdomen, and pelvis➔rule out
systemic disease
Fluorescence in situ hybridization (FISH) or polymerase chain reaction (PCR)
Diagnosis
Management
testing for t(11;18)
Unilateral bone marrow biopsy and aspirate
Endoscopy+H. pylori testing is the method of choice for diagnosis of gastric
lymphoma
Low-grade MALT lymphoma➔antibiotics against H. pylori (rst-line
treatment (response rate 70%)➔urea breath test in 4–8weeks to conrm
eradication➔20% require a second H. pylori eradication regimen
H. pylori eradication fails➔local radiotherapy results in high rates of overall
and complete responses
179
Factors associated with treatment
failure
Transmural extension, nodal involvement, transformation into a large cell
phenotype, t(11;18), or nuclear BCL-10 expression
Gastric polyps
Types Characteristic Management
Inammatory
broid polyps
Fundic gland
polyps
Hyperplastic
polyps
Often ulcerated, solitary, and sessile Resection (due to their very low
malignant potential, endoscopic
surveillance is usually not needed)
Multiple, with a smooth surface
Hyperemic and sessile
No malignant potential when associated with use of PPI
Most common polyp type
Stalked, smooth, or dome shaped
Occur anywhere in the stomach
Low malignant potential
Result from hyper-regenerative epithelium in response to
an underlying chronic inammatory stimulus in the setting
of chronic inammatory conditions (chronic atrophic
gastritis, H. pylori, pernicious anemia, adjacent to ulcers
and erosions, and gastroenterostomies)
≥1cm in diameter, ulcerated polyps
or polyps located in the
antrum➔resect to conrm the
diagnosis and rule out dysplasia or
neoplasia
Hyperplastic polyps measuring
>0.5cm➔resect
completely+assess for the presence
of dysplasia and H. pylori
Gastric
adenomas
Usually solitary and may be at or polypoid
Commonly found in the antrum, they are typically <2cm
in size
They may progress to adenocarcinoma
Due to malignant potential➔all
gastric adenomas must be resected
(endoscopically or surgically)
180
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Carcinoids
L. Amodu et al.
Carcinoids are slow-growing tumors of neuroectodermal origin
Characteristics
Histology Five histologic patterns: Insular (more favorable prognosis), trabecular (more favorable
Presentation
Appendicial
carcinoid
Originate from Kulchitsky or enterochromafn cells located in the crypts of Lieberkühn
Malignancy is often associated with carcinoid tumors >2cm that are often ulcerated with invasion
through the muscularis propria
Malignant carcinoids are differentiated from benign carcinoids based on increased cellular atypia,
high mitotic activity, and presence of necrosis
prognosis), glandular, undifferentiated, mixed
The liver is capable of metabolizing and inactivating most of the peptide hormones secreted by
carcinoid tumors➔carcinoid syndrome develops only after metastases have reached the liver
bypassing hepatic metabolism (patients with tumors involving lymph node metastases or directly
invade the retroperitoneum)
Malignant tumors of the appendix: Carcinoids (80%) and adenocarcinomas
Appendiceal carcinoid case Management
<2cm in size
Located at the tip or body of the
appendix
>2cm in size
Located at the base of the
appendix
Involve the mesocolon
Appendectomy
Right hemicolectomy to obtain adequate nodal sampling for
staging
Small bowel
carcinoid
Have high-risk features (mucin
production, lymphovascular
invasion, involvement of lymph
nodes, or with nodal or distant
metastases)
Appendiceal
carcinoid+metastasis to liver
Goblet cell carcinoid Are classied according to carcinoma scheme
The prognosis and survival of patients with liver metastasis from appendiceal carcinoids is
signicantly better than metastases from other tumors
Small bowel carcinoid Management
Locally limited disease Resection of primary tumor
Extensive disease Resection or bypass of primary tumor+debulking of
Tumor debulking (hepatic resection, cryotherapy,
chemoembolization, radiofrequency ablation, or hepatic artery
embolization)➔carcinoid metastases derive the their blood
supply from the hepatic artery
Stage I➔appendectomy alone
Higher stages➔right hemicolectomy
metastasis
6 Stomach
Carcinoids
181
Type Characteristic Management
Gastric
carcinoid
Type I
Type 2
Majority (70–80%) of all
gastric carcinoids are
associated with chronic
atrophic gastritis.
Gastric
achlorhydria➔increased
serum gastrin➔stimulates
neuroendocrine cell
hyperplasia in the
stomach➔multifocal
polypoid carcinoid tumors
Usually indolent clinical
behavior
Most are grade 1 tumors with
stage I disease
Metastasis is rare
5% of gastric carcinoid tumors
ZES or MEN type
1➔elevated serum gastrin
levels➔multifocal gastric
carcinoid tumors
Indolent clinical behavior, but
metastasis is more frequent
1–2cm➔endoscopic
resection
Antrectomy if there are
numerous progressive tumors
Extensive tumor involvement
of the gastric wall (which
increases the risk of a
coexisting adenocarcinoma),
tumor size >2cm (which
increases the risk of
metastases), poorly
differentiated histology, or
emergent
bleeding➔aggressive
surgical management
1–2cm➔endoscopic
resection
Colon and
rectal carcinoid
Associated
tumors
20% to 30% of gastric
carcinoids
Atrophic gastritis or ZES is
Type 3 (sporadic)
Carcinoid of colon most commonly occur in cecum>ascending colon
If carcinoid >2cm➔staging requires CT of the chest, abdomen, pelvis+MRI of the colon and
rectum
Carcinoid case Management
Carcinoid in colon Colectomy
Rectum
Carcinoid tumors are associated with increased risk of synchronous colorectal and small bowel
tumors as well as metachronous lung, prostate, and urinary tract neoplasms
absent
Gastrin is normal
The tumor is aggressive, and
metastasis is common
<1cm➔local excision
1–2cm➔local excision or proctectomy
>2cm➔proctectomy
Partial or total gastrectomy
with local lymph node
resection
182
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Gastric Adenocarcinoma
Gastric Adenocarcinoma
L. Amodu et al.
Risk factors Diets high in salt or smoked meats, smoking, helicobacter pylori infection, gastric
Genetic syndromes Hereditary diffuse gastric cancer, familial adenomatous polyposis, li-Fraumeni, and
Presentation Epigastric pain, obstructive symptoms, anemia, hematemesis, and melena
Diagnosis
Tumor marker CEA, cancer antigen (CA)-125, CA 19-9, and alpha fetoprotein
polyps, low socioeconomic status, individuals with blood group A, after gastric surgery
hereditary nonpolyposis colorectal cancer, pernicious anemia
CT abdomen and pelvis to rule out metastatic disease and can help with T and N staging
EUS is superior for T staging and nodal involvement if no metastasis found on CT
abdomen and pelvis
FNA of suspicious lymph nodes
PET is of limited usefulness (detects occult metastasis in 10% of cases)
Laparoscopy with peritoneal washings can be used to detect metastatic lesions before
undergoing a formal resection
Resection is based on location
Location of gastric cancer Management
Tumors in distal body or antrum Distal gastrectomy+reconstruction with Billroth
II or Roux-en-Y
Proximal transection with 6cm margins and 2cm
distal margin onto the rst portion of the
duodenum
Management
Tumors of the proximal gastric
body (cardia or fundus)
16 lymph nodes are recommended for staging➔2020 NCCN guidelines (previously
only 15 lymph nodes were recommended)
D2 nodal dissection➔if the surgeon is technically capable and experienced
Neoadjuvant therapy for locally advanced (T2 and above or any lymph node
positive patient based on EUS (Diag laparoscopy should be done prior to the
initiation of therapy)
Asymptomatic unresectable patients➔chemotherapy (triple therapy with
5-uorouracil, cisplatin, and an anthracycline-based compound (epirubicin))
Symptomatic unresectable patients➔resection for palliation of symptoms or
endoscopic stent placement
Total gastrectomy+Roux-en-Y reconstruction
6 Stomach
Gastric Adenocarcinoma
Japanese classication of gastric carcinoma (JCGC): 16 distinct anatomic locations
Level Characteristics Station/
Japanese classication
of gastric carcinoma
lymph node levels
D1 Perigastric nodes along the lesser and
greater curvature
183
level
Station
1–6
N1 level
Key steps
Follow up
D2 D1+nodes along left gastric,
common hepatic artery, celiac trunk,
splenic hilum, and splenic artery
D3 D2+nodes along hepatoduodenal
ligament, root of SMA/SMV
D4 D3+periaortic lymph nodes Station
Open the gastrocolic ligament by taking the short gastric arteries
Dissect the lesser omentum and the greater omentum and include with the specimen
Staple across the stomach at the necessary levels to provide more than 5-cm margins
Reconstruction with Billroth II gastrojejunostomy versus Roux-en-Y gastrojejunostomy
versus esophagojejunostomy
All stages➔history and physical exam every 3–6months for 1–2years, every
6–12months for 3–5years and annually thereafter
Stage I cancer: CT of the chest, abdomen, and pelvis as needed
Stage II, III, or IV cancers: CT of the chest, abdomen, and pelvis every 6–12months for
2years and then annually for up to 5years
Recurrence rates range from 40% to 80%
Station
7–11
N2 level
Station
12–15
N3 level
16
Recurrence
Most cancers recur within the rst 3years
Peritoneal dissemination➔54% of cases
Locoregional recurrence➔38–45% of cases
Locoregional recurrence occur at the anastomotic site, gastric bed, or regional lymph
nodes
184
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Research
Reference Findings
L. Amodu et al.
Songun I, Putter H, Kranenbarg EM, Sasako M,
van de Velde CJ.Surgical treatment of gastric
cancer: 15-year follow-up results of the
randomized nationwide Dutch D1D2 trial. Lancet
Oncol. 2010;11(5):439–49. Doi: https://doi.
org/10.1016/S1470- 2045(10)70070- X. Epub 2010
Apr 19. PMID: 20409751
Bunt AM, Hermans J, Smit VT, etal. Surgical/
pathologic-stage migration confounds
comparisons of gastric cancer survival rates
between Japan and Western countries. J Clin
Oncol 1995;13:19
Kozak KR, Moody JS.The survival impact of the
intergroup 0116 trial on patients with gastric
cancer. Int J Radiat Oncol Biol Phys.
2008;72(2):517–21. https://doi.org/10.1016/j.
ijrobp.2007.12.029. Epub 2008 Feb 4. PMID:
18249500
The extent of lymph node dissection is highly debated. D1
has been preferred in Western countries, arguing no
difference in survival for D1 versus D2 and higher
postoperative morbidity for D2. However, long-term
follow-up has shown increased disease-specic survival for
D2. Japanese studies have shown increased recurrence-free
survival for D2 dissection with minimal or no increased
morbidity
Overall, D2 dissection is preferred secondary to long-term
survival benet if postoperative morbidity at high-volume
centers can be minimized
In the USA, adjuvant chemotherapy and radiation therapy
(postoperative) have been shown to increase survival in
gastric cancer patients based on the INT-0116 trial
Gastric Foreign Bodies
Gastric foreign bodies
Epidemiology Children, especially those with developmental delays or autism
Diagnosis
Management
Older adults, incarcerated people, psychiatric patients, people with alcohol
intoxication
Biplane radiography (identify radiopaque objects such as coins, nails, and clips)
If foreign body is not identied on biplane radiograph and suspicion is high for
foreign body ingestion➔CT scan (identify nonradiopaque objects such as sh
bones and toothpicks)
80–90% of ingested foreign bodies pass without intervention; 10–20% require
endoscopic removal
Use a exible endoscope that includes two channels through which diagnostic and
therapeutic instruments can be passed
Glucagon 1mg IV can be used for food bolus impaction
Foreign object Device used for
retrieval
Long objects Snare
Round objects Retrieval net
Coins Forceps with teeth
6 Stomach
Case scenarios for management of gastric foreign bodies
Case Management
Object >6cm long or>2cm wide Endoscopic removal
Coins+symptomatic patient Urgent removal
Coin ingested+asymptomatic patient Endoscopic retrieval if object remain >3–4weeks
Sharp, pointed object Urgent endoscopic removal
>2 magnets Emergency endoscopic removal
Children who present >12h after ingestion are more susceptible
to perforation and stula. Ulceration of the gastric mucosa can
occur in less than 8h
Button battery ingestion+symptomatic Emergency endoscopic retrieval
185
Button battery+asymptomatic + child
Urgent endoscopic retrieval
<5years+battery ≥20mm in diameter
Button battery+asymptomatic+child
>5years+battery ≥20mm in diameter (no
Serial X-ray at 48h if battery >20mm or 14days if battery
≤20mm
magnet co-ingested)
Button battery+asymptomatic
Endoscopic removal
patient+button battery retained in stomach
after 10–14days+battery <20mm
Morbid Obesity
Morbid obesity
BMI BMI=weight (kg)/height (m2)
Classication Class I (obese)=BMI>25kg/m
Class II (morbid obesity)=BMI>35kg/m
Class III (super obese)=BMI>40kg/m
Indications for
bariatric surgery
• BMI>40 kg/m
• BMI>35 kg/m2+2 associated medical comorbidities
• Psychiatrically stable without alcohol dependance or illegal drug use or is being treated
Contraindications Patients who are unable to ambulate
Patients with Prader-Willi syndrome—Patients eat compulsively and cannot comply with
postoperative dietary restrictions
2
2
2
2
Physiology
Ghrelin Produced by enteroendocrine
cells in gastric fundus
Causes increased
food intake
Leptin Produced by adipocytes Opposed ghrelin
action
Appetite
suppressant
Roux-en-Y and sleeve gastrectomy decrease ghrelin levels (controversial)
Both increase PYY causing increased satiety
Increased GLP 1 which likely causes DM2 remission
Incretin effect increased
186
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L. Amodu et al.
Morbid obesity
Metabolic syndrome Metabolic syndrome is dened as presence of any three of the following ve traits:
• Abdominal obesity
• High triglycerides
• Low HDL
• Hypertension
• Fasting blood glucose ≥100mg/dL
Patients have insulin resistance, impaired hepatic uptake of insulin, systemic
hyperinsulinemia
Morbid Obesity Operations
Morbid obesity operations
Gastric band Sleeve gastrectomy Roux-en-Y gastric bypass
Key steps
Placed at the GE junction
The peritoneum at the angle of
his is divided to create an
opening between the angle of
his and the top of the spleen
The gastrohepatic ligament is
divided over the caudate lobe of
the liver
The anterior branch of the
vagus nerve and any aberrant
left hepatic artery are spared
The base of the right crus of the
diaphragm is identied, which
is then followed posteriorly and
inferiorly to the esophagus
while aiming for the angle of
his. A tunnel is created
Band is pulled through tunnel
and locked
The anterior gastric wall is
plicated over the band with
three or four interrupted,
nonabsorbable sutures
The entire greater curvature
is taken down, leaving intact
the tissue within 3 (4–6) cm
of the pylorus and up to the
angle of his and exposing
the left crus of the
diaphragm
A bougie is used, and the
stomach is divided from the
antrum to the angle of his by
sequential rings of the
stapler
A 10–15mL proximal gastric
pouch is formed
A location approximately 30–50
(100) cm distal to the ligament of
Treitz is chosen for division of the
jejunum. BP limb
Length of the Roux limb:
80–120cm if BMI of 40; 150cm if
BMI of 50 or greater
Roux limb can be brought up
retrocolic or antecolic
Creation of gastrojejunostomy
Creation of jejunojejunostomy
Mesenteric defects are closed
(peterson’s, transmesocolic,
jejunojejunostomy)
6 Stomach
Morbid obesity operations
Gastric band Sleeve gastrectomy Roux-en-Y gastric bypass
Gastric band
4-6 cm
from
pylorus
1 cm from
gastroesophageal
junction
Proximal
gastric pouch
Alimentary
or roux limb
Bypassed
stomach
Bilio-pancreatic
limb
187
EWL 35% loss of BMI 40% and 80% (45–60%)
70% and 80% EWL
EWL
Advantage Easily reversible
Relatively simple technique
Immediate resolution of symptoms
of GERD occurs in more than 90%
Technically simpler than bypass
Can be converted to a
of cases
RNYGB if no longer
desirable failed or
problematic complications
Mortality 0.03% 0.08% 0.1–0.2%
Complications Port infection
Band slippage: Acute onset
intolerance to food diagnosed
on a plain X-ray
Band erosion: Incidence of 1%
to 3%
Staple line dehiscence/
disruption/leak (97%
proximal)
Exacerbation of GERD
Stenosis, PE/DVT
Pulmonary embolism, anastomotic
leak
Leaks at the gastrojejunostomy are
more common than
jejunojejunostomy
GERD and esophageal dilation
Iron, folate, vitamin A, vitamin D,
or vitamin B12 deciencies
Marginal ulcer and stenosis,
dumping syndrome
188
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Complications ofMorbid Obesity Operations
Complications of morbid obesity operations and their management
Complication Characteristic Management
L. Amodu et al.
Pulmonary
embolism
Hypoxia, hypoxemia, dyspnea, tachycardia,
hypotension
Anastomotic leak Presents with tachycardia, fever, or abdominal pain
Leak from gastrojejunostomy is more common than
leak from jejunostomy
CT with oral contrast for diagnosis
Dumping Early: Rapid onset and due to hypersomolality.
Abdominal pain, diarrhea, tachycardia, hypotension
Late: Due to hyperinsulinemia and hypoglycemia.
Fatigue, diaphoresis, weakness
Internal hernia Could be through the jejuno-jejunal or Petersen’s
defects or a defect in the transverse mesocolon in
patients with a retrocolic Roux limb
Diagnosed with PO and IV contrast of abdomen and
pelvis
CTAP with transition point or mesenteric swirl (or
high index of suspicion LUQ and large weight loss)
Anticoagulation. May need mechanical
thrombectomy/thrombolysis if massive
or saddle embolus
Immediate reoperation, buttress repair
and drain
If contained and patient is stable may be
managed with a covered stent across the
gastrojejunostomy
Dietary and behavioral modication.
Avoidance of simple sugars, small
frequent meals, etc.
Same dietary modications as above.
May also need medications which slow
GI transit, e.g., octreotide
Immediate operative exploration:
Reduction of small bowel±bowel
resection and closure of defect
Proximal
gastric pouch
Alimentary
or roux limb
Bypassed
stomach
Herniation of the fundus through the band (either
superior or inferior)
Remove uid from band➔if symptoms
do not resolve➔operation to remove
band
Sudden development of food intolerance or,
occasionally, gastroesophageal reux
Band slippage
KUB: Band oriented in a horizontal or a 10- to
4-o’clock position (phi angle greater than 63 degree)
Slippage can cause life-threatening strangulation of
the stomach
Iron deciency Microcytic anemia, pallor, fatigue Dietary iron supplementation
Vitamin
Macrocytic anemia, sensory impairment, etc Dietary vitamin supplementation
deciency
Biliopancreatic
limb
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