Case Presentation, Management, Discussion and Sharing of Information on Epigastric Pain Jonathan R....

Case Presentation, Management, Discussion and Sharing of

Information on Epigastric Pain

Jonathan R. Malabanan, M.D. Surgery Resident

OMMC

DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER

“Towards Patient Safety in Surgery”

General Data:

• L.B. 42 y.o male

• Quiapo, Manila.



Chief Complaint

Epigastric Pain



History of Present Illness:

• 1 month PTA→ (+) epigastric pain, on and off associated with postprandial vomiting

(+) consult private MD: Ranitidine

UTZ: Suspicious tubular density at epigastric region, Normal liver, gall bladder and common bile duct.



→EGD with biopsy:

nodular mass at pylorus area

multiple erosion from pylorus to the body

Biopsy: poorly differentiated gastric adenocarcinoma



• 1 wk PTA →(+)persistence of epigastric pain and post-prandial vomiting with associated anorexia

(+) progression of above conditions

advised to undergo CT Scan



→Consulted our hospital due to financial constraint.



PAST MEDICAL HISTORY:

• No DM

• No Hypertension

• No other heredofamilial diseases



PHYSICAL EXAMINATION:• GEN SURVEY:

Conscious,coherent,oriented

BP=120/80 CR=80 RR=21 T=36.5• HEENT: Pink conjunctivae, anicteric

sclerae, no cervical lymphadenopathies

• CHEST: SCE, clear breath sounds



PHYSICAL EXAMINATION:PHYSICAL EXAMINATION:

• CARDIAC: Normal rate, regular rhythm, no murmur

• ABDOMEN: Flabby, NABS, soft, no palpable mass

• EXTREMITIES: Full and equal pulses,no deformities

• DRE: No mass noted, good sphincter tone, with feces on tactating finger



Salient Features:• 42 y.o male

• (+) epigastric pain, on and off associated with post-prandial vomiting

• (+) anorexia

• (+) UTZ: Suspicious tubular density at epigastric region, Normal liver, gall bladder and common bile duct.



Salient Features:

(+) EGD with biopsy:

nodular mass at pylorus area

multiple erosion from pylorus to the body

Biopsy: poorly differentiated gastric adenocarcinoma



AlgorithmEpigastric Pain

post-prandial vomiting

Gastric ulcer Tumor

EGD with biopsy: nodular mass on pylorus with

mucosal erosion up to the body



AlgorithmEpigastric Pain

post-prandial vomiting

Gastric ulcer Tumor

Benign MalignantBiopsy: poorly

differentiated adenocarcinoma



Clinical Diagnosis

DIAGNOSIS CERTAINTY TREATMENT

PRIMARY Gastric AdenoCA Resectable

85% Surgical

SECONDARY Gastric AdenoCANon resectable

15% Palliative surgeryChemotheraphyRadiation



PARACLINICAL DIAGNOSTICPROCEDURE

• Do I need a paraclinical diagnostic procedure?

Yes.



Paraclinical Diagnostic OptionsBENEFIT RISK COST AVAILABI

LITYCT Scan Sensitivity: 88

%Specificity: 86 %- Lymph node involvement Direct invasionDistant of metastases

-Radiation P10- 20 thou Not available

Diagnostic ExploreLaparotomy

Sensitivity:Specificity:May proceed with definitive treatment

-Infection-Hemorrhage

P30-40 thou Available



Bryan J Dicken et. al. Gastric Adenocarcinoma. Review and Considerations for Future Directions. Ann Surg. 2005 January; 241(1): 27–39.

Pretreatment Diagnosis:

Gastric Adenocarcinoma, Pyloric area, Resectable



Goals of Treatment1. Complete removal of gastric cancer

2. Better long term improvement and prevent complication



Pre Treatment OptionsBENEFIT RISK COST AVAILABI

LITYSubtotal Gastrectomy

Same5 year survivalShorter hospital stayBetter nutritional status

-Hemorrhage P30-40 thou Available

Total Gastrectomy

5 year survival -HemorrhageIncreased post operative infection rate

P30-40 thou Available



Bryan J Dicken et. al. Gastric Adenocarcinoma. Review and Considerations for Future Directions. Ann Surg. 2005 January; 241(1): 27–39. Bozzetti F, Marubini E, Bonfanti G, et al. Subtotal versus total gastrectomy for gastric cancer: five-year survival rates in a multicenter randomized Italian trial. Italian Gastrointestinal Tumor Study Group. Ann Surg. 1999;230:170–178

Plan of Operation

• Subtotal Gastrectomy



Treatment Goal

• Better quality of life and increase survival



Pre Treatment OptionsBENEFIT RISK COST AVAILABILI

TY

Radical Subtotal Gastrectomy with D1 Dissection

Recurrence:41 %Hospital Stay: 14 days

Infection Rate: 25 %

P40 thou Available

Radical Subtotal Gastrectomy with D2 Dissection

Recurrence: 29 %Hospital Stay: 16 days

Infection Rate: 43 %

P30 thou Available



Bonenkamp JJ, Hermans J, Sasako M, et al. Extended lymph-node dissection for gastric cancer. Dutch Gastric Cancer Group. N Engl J Med. 1999;340:908–914. [PubMed

Plan of Operation

• Radical Subtotal Gastrectomy with D2 Dissection, Gastrojejunostomy (Billroth II)



PREOPERATIVE PREPARATION

• 1. Informed Consent

• 2. Psychosocial Support

• 3. Optimize Patient’s Physical Health

• 4. Screening For Other Medical Problem

• 5. Prepare Materials For OR



Operative Maneuvers

• Patient supine under GA

• Asepsis antisepsis

• Sterile drapes placed

• Midline vertical abdominal incision long enough to facilitate accurate intra-operative evaluation

• Liver inspected, stomach identified



Intraop- findings

• A nodular mass noted intraluminally at the pylorus area measuring 3x 4 cm

• No other organ involvement

• Perigastric and left gastric nodes noted



Operative Maneuvers

• Formal radical subtotal gastrectomy done

with D2 dissection and removal of omentum

Stomach was mobilized with division of right gastroepiploic artery, right gstric and gastrodudenal artery

A 6 cm margin tumor margin proximally was allotted removing more than 50% of the stomach



Operative Maneuvers

• Formal gastrojejunostomy was done with open end of the stomach attached to the jejunum.

• Jejunum passed in front of the colon and was attached to the stomach



Operative Maneuvers

-

-Hemostasis -OS and instrument

checked -Layer by layer closure -Dry sterile dressing

placed



Operation Done:

• Radical Subtotal Gastrectomy with D2 Dissection, Gastrojejunostomy (Billroth II)



Final DiagnosisGastric Adenocarcinoma, Pyloric Area S/P

Radical Subtotal Gastrectomy with D2 Dissection, Gastrojejunostomy (Billroth II)



Post op Management:• Maintained on NPO

• Adequate analgesia given

• Antibiotics continued

• Monitoring of early complications



Post op Management:• The nasogastric tube is removed upon return

of gastrointestinal transit, and feeding is slowly begun.



Sharing of Information



Epidemiology-highest incidence is in Japan

-occurs more frequently in males in almost all areas of the world

-slightly increased risk in patients with blood group A



Signs & Symptoms

• produces no specific symptoms when it is superficial and potentially surgically curable, although up to 50% of patients may have nonspecific gastrointestinal complaints such as dyspepsia.



Risk Factors

-Diets high in salt and cured and smoked food, low in fresh fruit and vegetable

-H. pylori infection

-smoking



Lauren ClassificationIntestinal Type• glandular and arise from the gastric

mucosa usually in older patients and more commonly in the distal stomach



Lauren ClassificationDiffuse Type

-associated with invasive growth pattern and appears to arise from lamina propria

-more common in proximal stomach and younger patients



SURGICAL MANAGEMENTTumors of the fundus and proximal stomach:

Total gastrectomy with D2 dissection and esophagojejunal reconstruction

Tumors of the body: Total gastrectomy with D2 nodal dissection

Tumors of the distal stomach: Subtotal gastrectomy with D2 nodal dissection



In the management of mid to proximal gastric cancers, sparing the tail of the pancreas and the spleen is recommended, if feasible, since it is associated with lesser morbidity and mortality.

D2 resection involves removal of the omental bursa, the hepatoduodenal and retroduodenal nodes (antral lesions) and the splenic artery and hilar nodes and retropancreatic nodes.



ADJUVANT THERAPY

Post-operative Adjuvant chemotherapy: Currently there is not enough evidence that will show benefit for post-operative chemotherapy.

Neo-adjuvant chemotherapy: several studies show promising results but still needs to be studied further. In cases of patients who are candidates for neo-adjuvant chemotherapy, staging using diagnostic laparoscopy is warranted.



FOLLOW-UP First follow –up within 5 – 7 days after discharge Second follow-up will be 30 days after the

operation. During the first year, frequency of follow-up will

be every 3 months, then every 6 months thereafter.

Yearly endoscopy Diagnostic work-up will be symptom-directed



References:

• Bonenkamp JJ, Hermans J, Sasako M, et al. Extended lymph-node dissection for gastric cancer. Dutch Gastric Cancer Group. N Engl J Med. 1999;340:908–914.

• Bryan J Dicken et. al. Gastric Adenocarcinoma. Review and Considerations for Future Directions. Ann Surg. 2005 January; 241(1): 27–39.

• Bozzetti F, Marubini E, Bonfanti G, et al. Subtotal versus total gastrectomy for gastric cancer: five-year survival rates in a multicenter randomized Italian trial. Italian Gastrointestinal Tumor Study Group. Ann Surg. 1999;230:170–178

• Cameron, John. Current Surgical Theraphy. Gastric Adenocarcinoma. Pp.95- 100.

• Treatment Protocol. Department of Surgery. UP- PGH



MCQ1.Which of the following characterizes

intestinal type of gastric ca?

a. associated with invasive growth pattern

b. appears to arise from lamina propria

c. glandular and arise from gastric mucosa

d. more common in proximal stomach

e. more common in younger patients



MCQ2. Most appropriate surgical treatment for

distal gastric ca?a. Total gastrectomy with D2 nodal dissection

b. Total gastrectomy with D1 nodal dissection

c. Subtotal gastrectomy with D2 nodal dissection

d. Total gastrectomy with D2 dissection and esophagojejunal reconstruction

e. Subtotal gastrectomy with D1 nodal dissection



MCQ3. A classic D2 dissection includes nodes

along the following except?

a. hepatic

b. left gastric

c. celiac

d. splenic

e. periaortic



MCRDirection: Write

“A” if 1, 2, and 3 are valid statements.

“B” if only 1 and 3 are valid statements.

“C” if only 2 and 4 are valid statements.

“D” if only 4 is a valid statement.

“E” if all are valid statements.



MCR4.With regard to the epidemiologic characteristic

of gastric ca, which of the following is/are true ?

1. The highest incidence is in Japan

2. Occurs more frequently in males

3. Incidence and death rates in US have decreased

4. Higher incidence among patients with blood group O



MCR5. With regard to surgical treatment of gastric

adenoCA, which of the following statements is/are true?

1.Total gastrectomy for antral lesions results in longer survival than does partial gastrectomy

2. Total gastrectomy for palliation is contraindicated

3..Extended LN dissection improves survival rates with stage I and II lesions



MCR5. With regard to surgical treatment of

gastric adenoCA, which of the following statements is/are true?

4. Routine splenectomy does not improve survival rates



Thank You!



Journal Appraisal

• Subtotal Versus Total Gastrectomy for Gastric Cancer

• Five-Year Survival Rates in a Multicenter Randomized Italian Trial

Ann Surg. 1999 August; 230(2): 170.Federico Bozzetti, MD,* Ettore Marubini, PhD,* Giuliano Bonfanti, MD,* Rosalba Miceli,

PhD,* Chiara Piano,* Leandro Gennari, MD,* and the Italian Gastrointestinal Tumor Study Groupe.



• Objective:

– To evaluate the impact of subtotal (SG) versus total (TG) gastrectomy on the oncologic outcome of patients with cancer of the distal stomach from 28 Italian institutions.



• Patients and Methods:.

• The present analysis involved 618 patients randomized during surgery to SG (315) or TG (303), provided there was at least 6 cm from the proximal edge of the tumor to the cardia, there was no intraperitoneal or distant spread, and it was possible to remove the tumor entirely. Both surgical treatments included regional lymphadenectomy.



• Results:

• Four patients died after SG and seven after TG. Median follow-up was 72 months after SG (range 2 to 125) and 75 months after TG (range 7 to 113). Five-year survival probability as computed by the Kaplan-Meier method was 65.3% for SG and 62.4% for TG.



• Results:

• The test of equivalence led to the conclusion that the two procedures may be considered equivalent in terms of 5-year survival probability.



• Results:

• The analysis of survival using a multivariate Cox regression model showed a statistically significant impact on survival of tumor site, tumor spread within the gastric wall, extent of resection to the spleen plus or minus neighboring organs or structures, and relative frequency of metastasis in resected lymph nodes..



• Conclusions:

• Both procedures have a similar survival probability. The authors believe that SG, which has been reported to be associated with a better nutritional status and quality of life, should be the procedure of choice, provided that the proximal margin of the resection falls in healthy tissue.



• Clinical Question:

• Will total gastrectomy increase the survival of patients with gastric ca on distal half as compared to subtotal gastrectomy?



• Tentative Answer

• No.



Are the results of the study valid?

Primary Guides:

1. Was the assignment of patients to treatment randomized?

Yes.




Primary Guides:

2. Were all patients who entered the trial properly accounted for and attributed at its conclusion?

Yes.




Secondary Guides:

3. Were patients, their clinicians, and study personnel "blind" to treatment?

Yes




Secondary Guides:

4. Were the groups similar at the start of the trial?

Yes.




Secondary Guides:

5. Aside from the experimental intervention, were the groups treated equally?

Yes.



God bless



Case Presentation, Management, Discussion and Sharing of Information on Epigastric Pain Jonathan R....

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