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FIGURE 4 • Completed Roux-en-Y reconstruction. (From Fischer et al.
Mastery of Surgery. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins,
2007, with permission.)
There are several potential pitfalls during a routine
gastrectomy. The gastrohepatic ligament might contain an
accessory left hepatic artery (15% to 20%) and sometimes
it represents the only arterial flow to the left lobe of the liver.
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Proximal ligation of left gastric artery in such case may
result in hepatic ischemia. Injury to the spleen or its vessels
may sometimes need splenectomy to control hemorrhage.
Positive esophageal resection margin may require reresection of the distal esophageal margin. When a
transhiatal esophagetomy is attempted for a GE junction
tumor, a positive gastric resection may sometimes need a
total esophagogas-trectomy with colon/jejunum
interposition. Stapled duodenal stump often does not need
further reinforcement with additional sutures; however,
when it looks ischemic, we recommend oversewing it with
Lembert sutures to prevent duodenal stump leak, which is a
disastrous postoperative complication.
Special Intraoperative Considerations
GE junction tumors extending into the body of the stomach,
where a 5 cm margin could not be achieved, will require
total gastrectomy with esophagectomy. We prefer colon
interposition in this situation. The left colonic segment
based on the ascending branch of the left colic vessels is
used. When the colon is absent or has extensive
diverticulosis, jejunal conduit can be used.
Postoperative Management
We place a nasogastric tube (threaded beyond the
gastrojejunal anastomosis intraoperatively), which is
maintained on low intermittent suction. Postoperative pain
control and early ambulation is the key to faster recovery.
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Jejunostomy feeding is started on post-op day 2. Drains
are removed on the fourth postoperative day if the bilirubin
and amylase in the drain fluid is less than three times the
serum values. Oral feeding is started once it is established
that the patient does not have an intra-abdominal leak from
esophagojejunostomy. A contrast swallow study can
effectively rule out a leak in this situation if it is suspected.
A dietitian can help the patient adapt to the changed eating
habit of small frequent meals. Multivitamin, B12, and iron
supplementation will be needed for life in case of total
gastrectomy. If the patient does not experience
complications, they are discharged home around sixth to
seventh postoperative day.
TAKE HOME POINTS
Upper GI endoscopy is diagnostic and EUS provides
the tumor and lymph node stage.
PET-CT is emerging as a vital diagnostic tool in
diagnosing regional as well as distant metastasis.
Most Siewert type II GE junction tumors are staged
and treated like an esophageal cancer.
Neoadjuvant chemotherapy has shown to improve
survival rate in locally advanced tumors and is being
recommended by many surgeons and oncologists.
Total gastrectomy with Roun-en-y
esophagojejunostomy remains the operation of
choice for locally advanced resectable proximal
(upper one-third) gastric carcinoma.
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Current NCCN guidelines state that at least 15 lymph
nodes should be retrieved for adequate staging,
mostly achieved through a D2 lymph nodal
dissection.
Postoperative chemotherapy and radiation is
advised for locally advanced cancers.
SUGGESTED READINGS
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chemotherapy then chemoradiation followed by surgery in patients with
potentially resectable carcinoma of the esophagus or gastroesophageal
junction. Cancer. 2001;92(2):279–286.
Avella D, Garcia L, Staveley-O’ Carroll K, et al. Esophageal extension
encountered during transhiatal resection of gastric or gastroesophageal
tumors: attaining a negative margin. J Gastrointest Surg.
2009;13(2):368–373.
Bonenkamp JJ, Hermans J, Sasako M, et al. Extended lymph-node
dissection for gastric cancer. N Engl J Med. 1999;340(12):908–914.
Bozzetti F, Bonfanti G, Bufalino R, et al. Adequacy of margins of resection in
gastrectomy for cancer. Ann Surg. 1982;196(6):685–690.
Cascinu S, Scartozzi M, Labianca R, et al. High curative resection rate with
weekly cisplatin, 5-fluorouracil, epidoxorubicin, 6S-leucovorin,
glutathione, and filgastrim in patients with locally advanced,
unresectable gastric cancer: a report from the Italian Group for the Study
of Digestive Tract Cancer (GISCAD). Br J Cancer. 2004;90(8):1521–
1525.
Chen J, Cheong JH, Yun MJ, et al. Improvement in preoperative staging of
gastric adenocarcinoma with positron emission tomography. Cancer.
2005;103(11):2383–2390.
Chua YJ, Cunningham D. The UK NCRI MAGIC trial of perioperative
chemotherapy in resectable gastric cancer: implications for clinical
practice. Ann Surg Oncol. 2007;14(10):2687–2690.
Cunningham D, Allum WH, Stenning SP, et al. Perioperative chemotherapy
versus surgery alone for resectable gastroesophageal cancer. N Engl J
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Med. 2006;355(1):11–20.
Cuschieri A, Fayers P, Fielding J, et al. Postoperative morbidity and
mortality after D1 and D2 resections for gastric cancer: preliminary
results of the MRC randomized controlled surgical trial. The Surgical
Cooperative Group. Lancet. 1996;347(9007):995–999.
Dooley CP, Larson AW, Stace NH, et al. Double-contrast barium meal and
upper gastrointestinal endoscopy. A comparative study. Ann Intern Med.
1984;101(4):538–545.
Ganpathi IS, So JB, Ho KY. Endoscopic ultrasonography for gastric cancer:
does it influence treatment? Surg Endosc. 2006;20(4):559–562.
Gotoda T, Iwasaki M, Kusano C, et al. Endoscopic resection of early gastric
cancer treated by guideline and expanded National Cancer Centre
criteria. Br J Surg. 2010;97(6):868–871.
Kinkel K, Lu Y, Both M, et al. Detection of hepatic metastases from cancers
of the gastrointestinal tract by using noninvasive imaging methods (US,
CT, MR imaging, PET): a meta-analysis. Radiology. 2002;224(3):748–
756.
Lee YT, Ng EK, Hung LC, et al. Accuracy of endoscopic ultrasonography in
diagnosing ascites and predicting peritoneal metastases in gastric
cancer patients. Gut. 2005;54(11):1541–1545.
Power DG, Schattner MA, Gerdes H, et al. Endoscopic ultrasound can
improve the selection for laparoscopy in patients with localized gastric
cancer. J Am Coll Surg. 2009;208(2):173–178.
Saikawa Y, Kubota T, Kumagai K, et al. Phase II study of
chemoradiotherapy with S-1 and low-dose cisplatin for inoperable
advanced gastric cancer. Int J Radiat Oncol Biol Phys. 2008;71(1):173–
179.
Sarela AI, Lefkowitz R, Brennan MF, et al. Selection of patients with gastric
adenocarcinoma for laparoscopic staging. Am J Surg. 2006;191(1):134–
138.
Smith JW, Moreira J, Abood G, et al. The influence of (18)
flourodeoxyglucose positron emission tomography on the management
of gastroesophageal junction carcinoma. Am J Surg. 2009;197(3):308–
312.
Yang SH, Zhang YC, Yang KH, et al. An evidence-based medicine review of
lymphadenectomy extent for gastric cancer. Am J Surg.
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2009;197(2):246–251.
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16
Bleeding Gastric Ulcer
DANIELLE FRITZE and MICHAEL MULHOLLAND
Presentation
A 58-year-old man presents to the emergency room
following several episodes of coffee ground emesis.
While awaiting evaluation, he suddenly vomits a large
volume of bright red blood. As he is urgently
transported to a resuscitation bay, his wife explains that
he is generally healthy except for the stomach ulcer he
had the previous year. He completed a course of two
antibiotics for the ulcer and continues to take
omeprazole daily. He has never had an operation and
takes no other medications. On exam, the patient is
distressed but alert, oriented, and no longer vomiting.
Ini tial vital signs reveal tachycardia with a pulse of 115
and blood pressure of 100/70. He has mild discomfort
with deep palpation in the epigastrium, and the
remainder of his exam is unremarkable.
Differential Diagnosis
For patients presenting with upper gastrointestinal (GI)
bleeding, the source may be located in any portion of the GI
tract, from the oropharnyx through the ligament of Trietz
(Figure 1). Peptic ulcers are the most common cause of
upper GI hemorrhage requiring hospitalization, implicated
in nearly half of all cases. Mallory-Weiss tears, esophageal
varices, and erosive disease each account for an
additional 10%. While neoplasms such as
adenocarcinoma or gastrointestinal stromal tumor (GIST)
are less common sources, their accurate identification is
particularly important for treatment planning. Rare causes
of GI hemorrhage include Dieulafoy’s lesions, gastric
varices, and hemobilia.
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FIGURE 1 • Sources of upper gastrointestinal bleeding.
Although the differential diagnosis for upper GI bleeding
is broad, individual patient risk factors may point to a
particular source. For example, patients with portal
hypertension are at particular risk of variceal bleeding. In
anyone who has had an aortic aneurysm repair,
aortoenteric fistula must be immediately considered as a
potentially lethal source of GI hemorrhage. This patient’s
ulcer history makes a recurrent gastric ulcer the most
probable source of hematemesis.
Workup
Immediate management of upper GI bleeding is dictated by
the patient’s clinical condition. If the airway may be
compromised by bleeding or diminished mental status, the
patient should be intubated. Adequate intravenous access
should be established promptly, with administration of
crystalloid or blood products as appropriate for the
patient’s vital signs and rate of blood loss. Patients taking
warfarin or antiplatelet agents are likely to require reversal
of their coagulopathy. Nasogastric (NG) tube placement
can be diagnostic of an upper GI bleed if bright red blood is
aspirated. NG tube placement also allows for evacuation of
gastric contents and a rough estimation of the rate of
bleeding.
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History and physical exam are rarely diagnostic for a
bleeding ulcer but may provide information useful in its
management. Most patients with gastric ulcers report
symptoms of gnawing or burning epigastric pain with a
waxing and waning course. Classically, discomfort from
gastric ulcers is exacerbated by oral i ntake. Slow, chronic
blood loss may cause melena and lead to symptoms of
anemia. Identification of risk factors for ulcer development
such as nonsteroidal anti-inflammatory drug (NSAID) use,
smoking, or multiple endocrine neoplasia type I syndrome
(MEN I) lends insight into the underlying etiology of the
ulcer. Knowledge of any anticoagulant or antiplatelet agents
taken by the patient allows for appropriate management of
the associated coagulopathy. Physical exam is often
unremarkable in ulcer patients, but some will exhibit
epigastric tenderness. Peritoneal signs raise concern for
perforation that infrequently accompanies hemorrhage. In
the acutely bleeding patient, the main utility of physical
exam is to identify signs of shock and estimate the degree
of blood loss.
In parallel with the initial resuscitation, diagnostic
studies are undertaken. Serum hematocrit, coagulation
profile, and blood type and screen are obtained; hematocrit
is followed serially. Peritoneal signs should prompt an
upright chest x-ray to evaluate for pneumoperitoneum. In the
absence of peritonitis, no imaging studies are necessary.
Esophagogastroduodenoscopy (EGD) is the most effective
means of locating the source of upper GI bleeding, with
successful identification of the responsible lesion in 95% of
patients. In rare cases where the source of bleeding is not
located on initial endoscopy, repeat EGD, angiography, or
technetium-99m–labeled red blood cell scan may be
successful.
Diagnosis and Treatment
Once a gastric ulcer is identified, endoscopic therapy is
guided by the risk of recurrent hemorrhage and the
patient’s clinical stability. Although bleeding frequently
resolves spontaneously, specific stigmata of hemorrhage
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predict continued or recurrent bleeding and the need for
intervention (Table 1). Ulcers with evidence of active
bleeding or a visible vessel within the lesion (Forrest grade
1a, 1b, and 2a) are at highest risk. Ulcers with an adherent
clot and underlying oozing are also prone to recurrent
bleeding. Endoscopic intervention is indicated for each of
these high-risk lesions. Options include the application of
clips, thermal coagulation, or injection of a vasoconstricting
or sclerosing agent. When feasible, biopsy of the ulcer is
important to identify any associated malignancy. Antral
biopsies are used to establish a histologic diagnosis of
Helicobacter pylori.
For patients with a bleeding ulcer,
endoscopic interventions carry a 90% success rate in
achieving initial hemostasis. If a patient rebleeds after
endoscopic intervention, a second endoscopic attempt at
hemostasis is made and has been demonstrated in a
randomized trial to be safer than proceeding to surgery.
However, for bleeding that cannot be controlled
endoscopically (after two attempts), or for patients with
hemorrhagic shock, surgery may be lifesaving.
TABLE 1. Forrest Classification of Peptic Ulcers
Following initial hemostasis, the etiology of the ulcer
must be identified and addressed.
H. pylori
and NSAIDs
are the two most important factors contributing to the
development of gastric ulcers (Table 2). Each is implicated
in over 50% of cases, with additive effects. Tobacco use is
also contributory. Four percent of gastric ulcers harbor an
underlying malignancy, most commonly gastric
adenocarcinoma. In rare cases, Zollinger-Ellison syndrome,
either sporadic or associated with MEN I, may be at fault.
Ulcer location may also offer insight into etiology.
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