Template – Gastric Carcinoma (Epigastric Mass)

HISTORY

·         Age – 7^th decade

·          

INVESTIGATIONS

1.      To confirm the diagnosis

a.      Esophago-gastro-duodenoscopy

                                                              i.      Direct visualization of the lesion

                                                            ii.      Site and size of the lesion

                                                          iii.      Brush cytology to improve diagnostic yield

                                                           iv.      Vital dye spraying (indigo carmine) – accentuate early gastric cancer and facilitate target biopsies

b.      Barium meal follow through with double contrast medium

2.      For staging (TNM staging)

a.      USS abdomen

                                                              i.      Liver secondaries

                                                            ii.      Para aortic lymph node

                                                          iii.      Ascites

b.      Endoscopic USS

c.       Contrast enhanced CT

                                                              i.      Expensive

                                                            ii.      Irradiation

                                                          iii.      Better soft tissue enhancement

                                                           iv.      Assess distant disease

d.      Laparoscopy

                                                              i.      Tumor deposits < 5 cm in peritoneal surface

                                                            ii.      Can take biopsies

3.      For assess fitness for surgery and anaesthesia

a.      Hematological

                                                              i.      Hb%

                                                            ii.      PCV

                                                          iii.      WBC/DC, platelet

b.      Biochemical

                                                              i.      FBS

                                                            ii.      BU

                                                          iii.      SE

                                                           iv.      Serum proteins

                                                             v.      PT/INR

                                                           vi.      SGOT/PT

                                                         vii.      ALP

                                                       viii.      CXR

                                                           ix.      SD echo

                                                             x.      Lung function tests

MANAGEMENT

1.      Treatment

a.      Curative

                                                              i.      Early gastric carcinoma – endoscopic mucosal resection

                                                            ii.      Advanced –

1.      total gastrectomy and roux-en-y oesophagojejunostomy

2.      Bilroth 1 partial gastrectomy + gastroduodenostomy

3.      Polya partial gatrectomy

b.      Palliative

                                                              i.      Gastro jejunostomy

                                                            ii.      Laser therapy for obstruction

                                                          iii.      chemotherapy

2.      Pre-op preparation

a.      Informed written consent

b.      Optimize cardiopulmpnary functions

c.       Nutrition optimization if

                                                              i.      BMI < 18.5

                                                            ii.      Body weight < 90% of predicted

                                                          iii.      > 10 % weight loss

                                                           iv.      High protein/calorie diet + vitamins + minerals

d.      Dentist for oral hygiene

e.      In gastric outlet obstruction – NG and aspiration/ gastric wash

f.        Chest physiotherapy

g.      Steam inhalation

h.      Breathing exercises

i.        Hg at least > 8 mg/dl

j.        Correction of PT/INR

k.       Refer to consultant anaesthetist

l.        Shower

m.    Overnight  fasting

n.      Grouping and DT for 2 pints of blood

o.      On the day of the surgery

                                                              i.      Make sure all the investigations are ready

                                                            ii.      Stomach wash

                                                          iii.      16 guage cannula

                                                           iv.      NG

                                                             v.      Catheter

                                                           vi.      Antibiotics

3.      Post op management

a.      PR, RR, BP, T

b.      Hourly UOP

c.       Bleeding PR

d.      Abdominal girth

e.      Dressing

f.        Epidural analgesia or IM pethidine 75 mg + promethazine 25 mg

g.      IV fluids 2 pints N/S and 3  pints dextrose for 24 hours

h.      Metronidazole 500 mg IV 8 hourly

i.        Gentamycine 80 mg IV 8 hourly

j.        Prop up

k.       Steam inhalation

l.        Chest physiotherapy

m.    Early mobilization

n.      Jejunostomy feeds from 2^nd post op day

o.      Remove drains and catheter when the indication is over

p.      Gastrography on 10^th post op dayto know the intergrity of the GIT

q.       Oral feeds

r.       Remove sutures

4.      Complications

a.      Early

                                                              i.      Local

1.      Bleeding – primary and reactionary

2.      Anastomotic leakage – gastric/ duodenal fistula, peritonitis, intra-abdominal abscess

3.      Haematoma

4.      Seroma

5.      Bburst abdomen

6.      Incisional hernia

                                                            ii.      General

1.      Hypostatic pneumonia

2.      MI

3.      DVT

4.      Pulmonary embolism

b.      Late

                                                              i.      Mechanical

1.      Small stomach

2.      Early morning bilious vomiting

3.      Dumping syndrome

4.      Intestinal hurry

                                                            ii.      Nutritional

1.      Fe deficiency

2.      Vitamin B 12 deficiency

3.      Fat malabsorption

4.      Vitamin D deficiency

5.      Immunodeficiency

6.       

5.      Prognosis

a.      Early gastric carcinoma – 5 year survival rate is > 90%

b.      Late gastric carcinoma

c.       Overall in Sri Lanka is 5%