B18. Malignant tumors of the stomach

Introduction

For introduction, epidemiology, etiology, and classification, see the corresponding pathology 2 topic.

Clinical features

The stomach is large and spacious, meaning that the tumour may grow large before symptoms appear. Early symptoms of gastric cancer include dyspepsia and mild epigastric discomfort or pain. Later, symptoms like anorexia, early satiety, weight loss, anaemia, and nausea/vomiting.

Diagnosis and evaluation

Physical examination may reveal a tumour in the epigastrium, and an enlarged Virchow’s node (left supraclavicular lymph node). DRE may reveal positive Blumer sign.

Upper endoscopy is the investigation of choice, as it allows for both visualisation and biopsy. After the diagnosis, CT thorax and abdomen are necessary for staging.

If peritoneal carcinosis is suspected but not visible on imaging, laparoscopy may be necessary to visualise the peritoneum and diagnose the carcinosis. Cytology may be obtained from the ascitic fluid.

Treatment

Stages I – III are curable, with metastatic gastric cancer usually being incurable. Cancers located only in the mucosa or submucosa (“early” gastric cancer) may be treated endoscopically or with minimally invasive surgery.

The standard curative surgical treatment for “advanced” gastric cancer patients is radical gastric resection with lymphadenectomy. For intestinal type gastric cancer, distal or subtotal gastric resection is performed. For diffuse type gastric cancer, total gastrectomy is necessary.

Billroth I refers to the procedure where the distalmost part of the stomach is resected, and an anastomosis is formed between the duodenum and the remaining distalmost part of the stomach in an end-to-end fashion. This can only be performed if the cancer is located distally in the stomach, close to the pylorus. This procedure is rarely performed anymore, and never in the surgical unit of POTE.

Billroth II refers to the procedure where a larger resection of the stomach is performed, and an anastomosis is formed between the side of the duodenum and the side of the remaining stomach in a side-to-side fashion. This procedure allows for a larger resection of the stomach than Billroth I. However, Billroth II allows bile to reflux into the stomach, which causes metaplasia and cancer progression in the remaining stomach or oesophagus. As such, Billroth II is rarely performed anymore, and never in the surgical unit of POTE.

The Roux-en-Y reconstruction surgery is the most frequently performed, as it prevents bile reflux. The stomach is separated from the bile-containing duodenum by a strand of jejunum 50 cm long. It is difficult to explain how this works, so I’ll allow this image to do the explaining:

Surgery may be used palliatively as well, in cases where the tumour obstructs passage of foodstuffs, for example. A stent may be placed, the stomach may be resected, or bypass surgery may be employed.

Chemotherapy may be used neoadjuvant for downstaging (to allow for surgery with curative intent), as adjuvant therapy, and as palliative therapy.


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B14. Colorectal tumors

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B21, 22. Squamocellular carcinoma and adenocarcinoma of the oesophagus and their surgical management

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