Stomach Flashcards
Stigmata of high risk gastric ulcers prone to re-bleeding
Active bleeding vessel visible vessel Adherent clot
Reason for biopsies during endocscopy for bleeding uler
Cancer (4% of ulcers) H. Pylori
Modified Johnson classfication for gastric ulcers
Indication for (and type of gastric ulcers) vagotomy and antrectomy (or pyloroplasty)
Type II or III (acid hypersecretion) ulcers resistant to PPI or H.pylori eradication.
vessels needing divided in distal gastrectomy
Right gastroepiploic near GDA
Right gastric
Branches of left gastric
(divide duodenum, stomach 1/2 way between duo and GE junction)
Definition of failure of nonoperatie managmeent for bleeding gastroduodenal ulcers
- HD instability despite 6 units of blood
- Failure of endoscopic management x 2
- Failure or inability of IR to embolize
- slow ooze with > 3 units of blood per day despite endoscopy and IR
Three points of suture for bleeding posterior duodenal ulcer plus other surgical principles
- superior
- inferior
- medial
Taking care not to injure CBD (may need bile duct probe through cystic duct). Generous Kocher maneuver. Longitudinal pyloroduodenotomy. Biopsies of ulcer bed if possible. Approximation of defect. Close transversely (Heineke).
Jaboulay pyloroplasty
does NOT cross the pylorus
Finney pyloroplasty
Crosses the pylorus
Vagotomy location to ensure Criminal nerve of Grassi is included
4-6 cm proximal from GE junction.
Work up for gastric cancer (essentially same as esophageal cancer)
- EGD w biopsy
- CT C/A/P
- PET
- EUS
- CBC, bmp, Her testing
- Siewart classification
- Possible diagnostic laparoscopy (really for all getting pre operative therapy)
Surveillance for gastric cancer
same as colon cancer except CT C/A/P annually up to 5 years
PET as indicted
watch for B12 and iron deficiency
Unresectable (aside from metastatic disease) for gastric cancer
Invasion of root of mesentery or positive para-aortic LN
Invasion of arterial structures (excpet for splenic artery)
D1 reseaction
Perigastric LN with greater and lesser omentum
D2 resection
D1 + LN dissection along celiac axis (commong hepatic, splenic, left gastric, and celiac) Do not do splenectomy.
Genetic syndromes pre-disposed to gastric cancer
- Hereditary diffuse gastric cancer - CDH1 - AD
- Lynch syndrome - AD
- Juvenile polyposis syndrome - AD
- Peutz Jeghers - AD
- FAP and attenuated FAP - AD
- Bloom syndrome
- Hereditary breast cancer syndrome
- Ataxia telangiectasia
- Li fruemeni
- Xeroderma pigmentosum
- Cowden syndrome
Hereditary diffuse gastric cancer prophylacitc surgery
CDH1
prophylactic gastrectomy (without D2 LN dissection) between 18-40 with frozen sections of esophageal and duodenal margin to ensure gastric tissue removed.
Screening needed for gastric cancer
- Juvenile polyposis - age 15 - annual if polyps otherwise 2-3 years
- peutz jeghers - late teens - every 2-3 years
- FAP - no need for stomach, but need duodenum starting 25-30 yo
STage II gastric cancer
- T1, T2 any N
- T3, T4 (N0)
Perioperative therapy for gastric cancer (T2 or above)
OS in FLOT vs ECF was 50 vs 35 months
Perioperative FLOT (5FU, Leucovorin, Oxaliplatin, Docetaxol) if good performance status
Perioperative FOLFOX of moderate performance status
Post operative chemoradiation if recieve less than D2 LN dissection.
Stomach NETs (3 types and treatment)
- Associated with atrophic gastritis - indolent course - Endoscopic resection or antrectomy for growing lesions
- Associated with separate gastrinoma - need to resect gastrinoma, endoscopic resection of gastric NET, antrectomy for growing lesions
- Non gastrin-associated, aggressive, need radical resection with LAD
BMI with higher Nissen failure rates (should consider R n Y)
BMI > 35
Nerve of Laterjet
Anterior division of anterior vagus (innervates the anterior stomach)
Bismuth quadruple therapy (10-14 day treatment)
Bismuth, flagyl, tetracycline, PPI
Triple therapy (treatment for 10-14 days)
Amoxicillin/flagyl, clarithromycin, PPI (reduced clearance rates compared to quadruple therapy)
Forrest IA and chance of rebleeding
Arterial or spurting hemorrhage; 90%
Forrest IIA and chance of rebleeding
visible vessel; 50%
Forrest IIB and chance of rebleeding
Adherent clot; 30%
Forrest III and chance of rebleeding
clean ulcer base; 5%
Indications for adjuvant therapy with Gleevac for GIST
> 3cm and > 5 mitoses per HPF
Minimal size for “giant” ulcer/perforation
> 2 cm (not appropriate for Graham patch)
Stitch pattern for bleeding duodenal ulcer
Treatment for gastric carcinoid (polyps) and hypergastrinemia
antrectomy
Percent of duodneal ulcers, gastric ulcers with H. pylori. Percent of H.pyorli infection causing ulcer
100%, 70%, 20%
Time course for early dumping syndrome (hyperosmolar load)
30 min
Time course for late dumping syndrome (high insuling)
2-3 hours
Agent for dissolution of phytobezoar
cola
3 types of Gastric carcinoid; associations; aggressivness
Type I: atrophic gastritis, small polyps; not aggressive - antrectomy
Type II: ZE; MEN1; slow growing, but can metastasize
Type III: not associated with gastrin; large; aggressive and metastasize
most common extranodal site of non-hogkins lymphoma. What are the two most common types
Stomach: large B cell followe by MALT oma
3 factors predicting risk of tumor recurrence after GIST resection
size (> 5 cm)
mitotic rate (> 5/50 HPF)
location (stomach, small bowel, colon)
