STOMACH CARCINOMA

SURGICAL ANATOMY
SURGICAL ANATOMY
INTRODUCTION
The stomach functions as:

A reservoir for ingested food.

To break down foodstuffs mechanically and commence the
processes of digestion before these products are passed on into
the duodenum.
ANATOMY

The stomach contains four anatomic regions:

1. Fundus.
2. Cardia.
3. Body.
4. Pyloric part contains pyloric antrum, pyloric canal.
The duodenum is 20–30 cm in length. It extends from pyloric
sphincter to ligament of Treitz. It is divided into four parts.
ARTERIAL SUPPLY
Left gastric artery, a branch of coeliac artery (Smallest branch
of coeliac axis).
Right gastric artery, a branch of hepatic artery.
Gastroduodenal artery, a (largest) branch of hepatic artery.
Right gastroepiploic artery, a branch of gastroduodenal artery.
x Left gastroepiploic artery, a branch of splenic artery.
Short gastric arteries, branches of splenic artery.
VENOUS SUPPLY
Right and left gastric veins drain into portal vein.
Right gastroepiploic vein drains into superior mesenteric vein.
Left gastroepiploic vein and short gastric veins drain into splenic
vein.
Prepyloric vein of Mayo distinguishes pyloric canal from the first
part of duodenum.
NERVE SUPPLY
Intrinsic innervation occurs through myenteric plexus of Auer- bach and submucous plexus of Meissner.

Right vagus is posterior and left vagus is anterior.

Posterior vagus gives criminal nerves of Grassi, which supply lower oesophagus and fundus of stomach, which, if not cut properly during
vagotomy, may lead to recurrent ulcer.

Vagus also gives splanchnic branches (hepatic and coeliac branches), ends as nerve of Latarjet which supplies the antrum and maintains the antral
pump.

Parietal branches help in HCl secretion, which is an important concept in vagotomy that is done as a treatment in duodenal ulcer.

Truncal vagotomy with posterior gastrojejunostomy is done for chronic duodenal ulcer with pyloric stenosis.

Highly selective vagotomy (HSV) is done in case of uncomplicated chronic duodenal ulcer which is not responding to available medical line of
treatment.

In HSV, nerve of Latarjet is retained so as to retain antral pump and no drainage is required. Here only the fibres entering the stomach are ligated
close to the lesser curve to reduce the acid secretion.

In selective vagotomy splanchnic branches are retained but it is presently not done.
LYMPHATICS
The stomach is divided into four lymphatic territories as follows:

First, divide the stomach into right two-third and left one-third by a line along its long axis. Now divide the right two-third into upper two-third (area 1) and lower one-third (area
4), and left one-third into upper one-third (area 3) and lower two-third (area 2).

Area 1 is the largest area along the lesser curvature. The lymph from this area is drained into left gastric lymph nodes along the left gastric artery. These lymph nodes also drain
the abdominal part of the esophagus.

Area 2 includes the pyloric antrum and pyloric canal along the greater curvature of the stomach. (The carcinoma of the stomach most frequently occurs in this area.) The lymph
from this area is drained into right gastroepiploic lymph nodes along the right gastroepiploic artery and pyloric nodes, which lie in the angle between the first and second parts
of the duodenum.

Area 3 (also called pancreaticosplenic area) drains into pancreaticosplenic (pancreaticolienal) nodes along the splenic artery.

Area 4 includes the pyloric antrum and pyloric canal along the lesser curvature of the stomach. The lymph from this area is drained into right gastric nodes along the right
gastric artery and hepatic nodes along the hepatic artery.

The efferents from all these lymph node groups pass to the coeliac nodes.

Efferents from coeliac nodes enter the cysterna chyli through intestinal lymph trunk.

Gastric carcinoma: It commonly occurs in the region of pyloric antrum along the greater curvature of the stomach. The gastric cancer spreads by
lymph vessels to the left supraclavicular lymph nodes. The enlarged and palpable left supraclavicular node (Virchow’s node) may be the first sign of
gastric cancer (Troisier’s sign). The cancer cells reach the left supraclavicular lymph node through the thoracic duct.
HISTOLOGY

The gastric epithelial cells are mucus producing and are turned over rapidly. In the pyloric part of the stomach, and also
the duodenum, mucus-secreting glands are found.Most of the specialised cells of the stomach (parietal and chief cells) are
found in the gastric crypts. The stom- ach also has numerous endocrine cells.
PARIETAL CELLS
These are in the body (acid-secreting portion) of the stomach and line the gastric crypts, being more abundant distally.
They are responsible for the production of hydrogen ions to form hydrochloric acid. The hydrogen ions are actively
secreted by the proton pump, a hydrogen–potassium-ATPase (Sachs), which exchanges intraluminal potassium for
hydrogen ions. The potassium ions enter the lumen of the crypts passively, but the hydrogen ions are pumped against an
immense con- centration gradient (1 000 000:1).
CHIEF CELLS
These lie principally proximally in the gastric crypts and produce pepsinogen. Two forms of pepsinogen are described:
pepsinogen I and pepsinogen II. Both are produced by the chief cell, but pepsinogen I is produced only in the stomach. The
ratio between pepsinogens I and II in the serum decreases with gastric atrophy. Pepsinogen is activated in the stomach to
produce the digestive protease, pepsin.
ENDOCRINE CELLS
The stomach has numerous endocrine cells, which are critical to its function. In the gastric antrum, the mucosa contains G
cells, which produce gastrin. Throughout the body of the stomach, enterochromaffin-like (ECL) cells are abundant and
produce histamine, a key factor in driving gastric acid secre- tion. In addition, there are large numbers of
somatostatinproducing D cells throughout the stomach, and somatostatin has a negative regulatory role. The peptides and
neuropep- tides produced in the stomach are discussed later.
AETIOLOGY
1.ENVIRONMENTAL/OCCUPATIONAL/DIET/HABITS
*Smoking/alcohol/obesity
*Low vegetable diet,diet with low vit A and C
*Consuming red meat ,smoked salmon fish,cabbage, diet rich in nitrosamines, lead
*Viral infections like EBV virus
*occupational-Rubber/coal wrkers

2.PRECANCEROUS LESION
*H.pylori infection,chronic gastritis
*Pernicious anemia
*Intestinal metaplasia
*Adenomatous polyps
*Bening gastric ulcer
*Previous gastric surgeries
3.GENETIC AND FAMILIAL
*Mutation in E –CADHERIN and APC gene
*Inactivation of tumor suppressor gene p53
*Loss of heterozygosity in BCL2 gene
*HNPCC carriers
*Li Fraumen syndrome
*Blood group A
*Monozygotic twins carry more risk than dizygotic twins
*When both parents have gastric cancer,the sibbiling are at a risk of diffuse proximal
gastric ulcer
*Mutation of H –ras oncogene and over expression of c- cerb B2 gene
PATHOLOGY

1.GROSS TYPES Cauliflower type

ulcerative type
Leather bottle type[ Linitis Plastica]
2.LAUREN`S Intestinal type-
CLASSIFICATION -Favorable prognosis
-Polypoidal and superficial types are intestinal varieties
-Synchronous/polypoidal/superficial types are common
-Gastric mucosa is replaced with epithelium that represents small bowel mucosa
Diffuse type
-Poor prognosis
-Common in blood group A, young people and females
-Poorly differentiated/signet type
-Linitis plastica,ulcerative growth without glandular formation is common
others
 3.DEPENDING ON DEPTH OF INVASION Early gastric cancer[Japanese classification]
-Protruded
-Superficial—elevated
flat
depressed
-excavated
Advanced gastric cancer[Borrmans classification]
-Single,polypoidal carcinoma
-Ulcerated carcinoma with clear cut margins
-Diffuse carcinoma-Linitis plastica
-Unclassified

4.WHO HISTOLOGICAL CLASSIFICATION Adenocarcinoma

-pappilary adenocarcinoma
-Tubular adenocarcinoma
-Mucinous adenocarcinoma
-Signet ring carcinoma
Adenosquamous carcinoma
Squamous cell carcinoma
Undifferentiated carcinoma
Others-Unclassified carcinoma
AETIOPATHOGENESIS
DIET RICH IN VITAMIN C,E. HIGH CHRONIC H. PYLORI INFECTION
SALT DIET. SMOKED FOOD. GENE STOMACH
MUTATTION

CHRONIC SUPERFICIAL GASTRITIS

Intestinal metaplasia

Dysplasia

ATROPHIC GASTRITIS

Cancer stomach
PATHWAYS OF SPREAD
PROGNOSTIC FACTORS
CLINICAL FEATURES:
Most Patients present with advanced stage because they are no early specific signs and symptoms.
Symptoms:
Recent onset of loss appetite and weight
early satiety fatigue
Dyspepsia
Epigastric discomfort
upper abdominal pain (non radiating)
haematemesis, Melaena
SPECIFIC SYMPTOMS DEPEND ON SITE OF TUMOUR

Tumour in proximal region - present with dysphagi, haematemesis

Tumour in body of stomach - present as only mass per abdomen.
Tumour in pyloric region - may present with gastric outlet obstarution and vomiting .
 :
SIGNS

Grossly anaemic (Iron deficiency anaemia )

Cachexia
Mass abdomen –
Mass in pylorus lies
above the umbilicus which
is nodular hard.
With impaired resonance
,Mobile, Moves with
respiration
Jaundice
IF CANCER SPREADS VIA LYMPHATICS :

Palpable left supraclavicular lymph node also called

virchow's node ( TROISIER'S SIGN +Ve )

+Ve Rectovesical secondaries ( Blumer shelf ) :

On per rectal examination, it is felt indicating that the tumor
is metastasized to pouch of Douglas.
SECONDARIES IN UMBILICUS -

as sister joseph's nodules

Krukenberg tumors
Irish node ( enlarged axillary node )
Cutaneous secondaries
INVESTIGATIONS
FLEXIBLE ENDOSCOPY
CONTRAST RADIOLOGY
ULTRASONOGRAPHY(ENDOSCOPIC USG)
CT & MRI
PET – CT
LAPAROSCOPY
TO CONFIRM THE DIAGNOSIS
Flexible upper GI Endoscopy with directed
biopsy followed by histopathological
examination of the sample
 Flexible Upper GI Endoscopy
EGD(esophago gastro duodenoscopy)
Visual examination of the upper intestinal tract using a lighted, flexible fiberoptic or
video endoscope
Gold standard
More sensitive than conventional radiology (95% accuracy)
Advantages
- outpatient procedure
- no radiation exposure
- targeted biopsy form the lesion can be taken at the same setting
- diagnosis can be made more accurately
INDICATIONS
Ulcers in the upper GI tract
Tumours of the stomach or oesophagus
Severe/persistent Dysphagia
Undiagnosed upper abdominal pain or indigestion
Intestinal bleeding
Esophagitis and heartburn – unresponsive to medical therapy
Gastritis
CONTRAINDICATIONS
Shock
Acute MI
Peritonitis
Acute perforation
Corrosive injuries of oesophagus
 IF YOU SEE ULCER ASK YOURSELF BENIGN OR MALIGNANT
BENIGN
Round to oval punched
out lesion with straight
walls and flat smooth base
Smooth margins with
normal surrounding
mucosa
Mostly on lesser curvature
Majority <2cm
Normal adjoining rugal
folds that extend to the
margins of the base
MALIGNANT
Irregular outline with
necrotic or haemorrhagic
base
Irregular and raised margins
Anywhere
Any size
Prominent and oedematous
rugal folds that usually do
not extend to the margins
 Contrast Radiology
Single contrast/ Double contrast
Barium meal
Advantages
- sensitivity comparable to endoscopy
- Non invasive procedure
FINDINGS IN CARCINOMA STOMACH

Irregular filling defect

Loss of rugosity
Delayed emptying
Dilatation of stomach in carcinoma pylorus
Decreased stomach capacity in linitis plastica
Carmanns meniscus sign
 Ultrasonography
Endoscopic / Endoluminal ultrasound is useful to detect the
involvement of the layers of the stomach, nodal status and to
differentiate early from advanced cancer
Excellent at determining the T- stage(90%)
High frequency probes used to differentiate T1-2 stage
Nodal status can also be assessed
Limited use in advanced disease
 CT and MRI
Every patient with a histological diagnosis of gastric
carcinoma should undergo a CT of chest and abdomen.
Provides information about
- M stage (Liver, Lung, Peritoneum and distant nodes)
- T4 stage (involvement of adjacent structures)
 Laparoscopy
To stage the disease especially in locally
advanced tumours
peritoneal secondaries
Occult metastasis
Peritoneal lavage for cytology
Biopsy of the peritoneum and nodes
 Signs of inoperability
Peritoneal deposits
Fixity
Liver secondaries
Fixed iliac nodes
Para aortic nodes
Ascitic fluid positivity
Sister Mary joseph nodule
Left axillary lymph node secondaries
 Other tests
Left supraclavicular node biopsy
Tetracycline fluorescence test
CA 72-4 in relapse , CEA, CA 19-9, CA 12-5
Combined PET-CT
Sentinel node biopsy
HB, Hematocrit, LFT, PT
TREATMENT
Surgery Is the treatment of choice for carcinoma stomach.
If it is an early growth ,as in case of pylorus,LOWER RADICAL
GASTRECTOMY is done.
Incase of growth in the upper part of the stomach, UPPER
RADICAL GASTRECTOMY is done.
in case of growth in the body or linitis plastica,TOTAL
GASTRECTOMY is Done.
ENDOSCOPIC MUCOSAL RESECTION(EMR) –tumor less than
2cm,elevated ,well –differenciated tumors without nodal disease is the
ideal selection for EMR.
PHOTO DYNAMIC THERAPY –is done which causes tumour
necrosis.
GASTRECTOMY
ADJUVANT THERAPYCHEMOTHERAPYmitomycin
10mg Iv single dose in monthly cycles.5-flourouracil ,
250 – 500mg IV in 5% dextrose daily for 5 days .
Cisplatin and epirubicin ,
adriamycin ,oxaliplatin ,capecitabin ,are other drugs
used at present.Chemoradiotherapy;postoperative
radiotherapy with chemotherapy using 5 FU and
luecovorin chemoradiation has been the standard
adjuvant treatment.Immunochemotherapyit is given in
stage 3 carcinoma after radical gastrectomy it starts from
5 operative day to end of 2 years .Residual cancer cells
th

or micrometastases can be irradicated by this therapy.l

PALLIATIVE TREATMENTpalliative procedures;palliative
partial/ total gastrectomy is the best palliation whenever possible.Palliative
anterior gastojejunostomy with jejunojejunostomy.Devine’s exclusion
procedure .Palliative chemotherapy is used in advanced stage .RT and
analgesia like morphine is used to relieve pain .Laser recanalisation. M-B
tube insertion for proximal stomach growths.Palliative chemotherapy – FAM
regime.
Anterior gastojejunectomy and devine’s exclusion procedure;