ABSITE REVIEW

Review session #21 Stomach

30 NOV 2006
Contributed by RODRIGO ARRANGOIZ

1. What is the blood supply of the stomach :

a. Celiac trunk: left gastric, hepatic, and splenic arteries.
b. Right gastric artery branch of the gastroduodenal artery or common hepatic artery /
c. Right gastroepiploic artery branch of the gastroduodenal artery branch of the common hepatic artery.
d. Left gastroepiploic artery branch of the splenic artery.

2. What is the location of the maximal parietal mass In the stomach?

Body followed by the fundus.

3. What is the criminal nerve of Grassi?

It is a branch of the right (posterior) vagal trunk that enters the fundus. Called this because sometimes overlooked in a
vagotomy leading to recurrence of ulcer.

4. What are the various types of vagotomies and the physiology on the stomach ?
a. Truncal vagotomy: division ot the right and left vagal trunks at the level of the esophagus ((level at the diaphragm
hiatus).
b. Selective vagotomy: divides the nerves of Latarjet preserves the celiac and hepatic trunks.
c. Highly selective vagotomy: divides individual fibers, preserves the crow's foot.
d. Vagal denervaton: all forms increases emptying of liquids (vagally mediated receptive relaxation and accommodation
of the stomach is lost, leading to increase gastric pressure.
e. Complete vagotomy (complete or selective) decreases the emptying of solids.
f. Highly selective vagotomy normal emptying of solids, normal or increase emptying of liquids.

5. What is the treatment of a perforated gastric ulcer :

a. Patient is hemodynamically unstable: exploratory laparotomy, Graham patch, will requires biopsy of the ulcer.
b. Hemodynamically stable patient: Graham patch and highly selective vagotomy if patient has already received PPI
therapy, biopsy the ulcer.

6. Treatment of a perforated duodenal ulcer ? Graham patch.

7. What are the endoscopic signs that show increase risk of rebleeding?
a. Visible vessel in the clot.
b. Gross bleeding
c. Adherent clot without oozing

8. How to you treat intractable bile gastritis following Billroth II ?

Conversion to a Roux-en-Y gastrojejunostomy with an afferent limb of 60 cm distal to the original gastrojejunostomy.

9. How do you treat gastric Maltoma:

Treat for H. Pylori 970 to 100%}regress if it does not may need chemotherapy (CHOP).

10. How do you treat gastric GIST tumor?

Surgical therapy The role of surgery in the treatment of a GIST is to resect the tumor with grossly negative margins and an
intact pseudocapsule. Lymph node involvement is rare with GISTs, and thus, no effort is made to perform ELND. The tumor must be
handled with care to prevent intra-abdominal rupture. Formal gastric resection is rarely required: as a rule, it is indicated only for
lesions in close proximity to the pylorus or the esophagogastric junction.
Nonsurgical therapy If the tumor has metastasized or has advanced locally to the point where surgical therapy would result in
excessive morbidity, the patient is treated with the tyrosine kinase inhibitor imatinibmesylate. (Gleevac) Imatinib is a selective
inhibitor of a family of protein kinases that includes the KIT-receptor tyrosine kinase, which is expressed in the majority of GISTs.
Originally indicated for the treatment of chronic myelocytic leukemia, imatinib was approved for the treatment of KIT-positive GIST
in 2002, when phase II clinical trials documented sustained objective responses in a majority of patients with advanced unresectable or
metastatic GIST. Patients with borderline resectable lesions should be treated with imatinib until they exhibit a maximal response as
documented by CT and positron emission tomography (PET); surgery may then be undertaken to resect any residual foci of disease.
Similarly, whereas patients with metastatic disease are unlikely to manifest a complete response to imatinib therapy, they should be
periodically reevaluated and considered for resection should surgical treatment become technically feasible.
After an R0 resection of a GIST, no adjuvant therapy is indicated unless the patient is participating in a clinical trial. The American
College of Surgeons Oncology Group is currently conducting two trials of imatinib in the postoperative setting. A phase II trial
(Z9000) of imatinib, 400 mg/day, for patients with high-risk GIST, has reached accrual, and a phase III trial (Z9001) comparing 1 year
of imatinib, 400 mg/day, with placebo in patients with intermediate-risk GIST is currently under way.
Gastric Carcinoid

11. What is the treatment choice for a 35 cm old female with BMI of 55 and associated co-morbilities such as DM and HTN?
Long limb gastric bypass surgery.

12. What are the indications for bariatric surgery? (data from 1991 NIH consensus conference)
a. BMI35-40 with significant obesity related comorbidities such as diabetes, sleep apnea, hypertension or degenerative joint
disease
b. BMI equal or greater than 40.

13. What are the risk factors for gastric cancer?

a. Previous gastric resection.
b. Nitrosamines.
c. Smoked fumes.
d. Menetrier's disease
e. Pernicious anemia.
f. Adenomatous polyps.
g. Blood type A.
h. Atrophic gastritis.

14. How to you treat early gastric cancer?

The current recommendation (at least according to the gurus who write ACS Surgery 2006) is to perform a subtotal gastrectomy
with Billroth II reconstruction for tumors of the distal stomach, a total gastrectomy with Roux-en-Y esophagojejunostomy for most
cancers of the fundus and the proximal stomach and either a transthoracic esophagogastrectomy or a transhiatal esophagogastrectomy
with gastric interposition for tumors of the esophagogastric junction and the cardia. This assumes the lesion is resectable. Although
there is conflicting evidence regarding the utility of an extended lyphadenectomy (the so-called D2 resection), most American
surgeons do a good D1 nodal dissection taking the perigastric lymph nodes on the greater and lesser curves of the stomach.

15.How do you classify gastric volvulus:

According to the axis around which the stomach rotates, gastric volvulus is classified as follows:
a. Organoaxial: The stomach rotates around an axis that connects the gastroesophageal junction and the pylorus. The antrum
rotates in opposite direction to the fundus of the stomach. This is the most common type in both children and adults and is
usually associated with diaphragmatic defects. Strangulation and necrosis commonly occur with this type and have been
reported in 5-28% of cases.
b. Mesentericoaxial The axis bisects both the lesser and greater curvatures. The antrum rotates anteriorly and superiorly so that
the posterior surface of the stomach lies anteriorly. The rotation is usually incomplete and occurs intermittently. Vascular
compromise is uncommon. Patients with this type usually present without diaphragmatic defects and usually have chronic
symptoms.
c. Combined This is a rare form in which the stomach twists both mesentericoaxially and organoaxially. This form is usually
observed in patients with chronic volvulus.