In remembrance of my late dear Pa Pa (in Burmese and English)

Dear Pa Pa,

                       Ah Mar and I were posing unknowingly under the Father’s day posters of Jusco, just infront of my clinic.

We missed you Pa Pa.

Please forgive me for all the sins I had committed on you.

I am praying for you every day, Pa Pa.

Your loving son

(Pa Pa, I am crying while writing this and uploading the photo below. May Allah keep you at the best place in Jannat / paradise)

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My dear father(may Allah bless his soul)  passed away on the day I went to Myanmar Embassy and applied a letter for his Passport to come here and to go to Saudi Arabia for Umrah or Haj. I kept this copy to send to Myanmar to attach with the application for Passports.

My late father was admitted to RGH on 1.7.1991. On doing laprotomy four days later, found the Ca stomach at the Cardia, all the doctores missed on investigation. The most famous Cardio-thoracic Dr Norman Hla had done Total Gastrectomy with oesophageo Ileal anastomosis. On 8th. day the anastomosis broke down and took the life of my dear father.

I thought it was just the laparotomy. Phone lines were disrupted. Even in Malaysia, there is only 12 lines for International calls and most of them were reserved for the government jobs, Wisma Putra, Embassies and Multinational business community. Once we got the phone call it was too later.

This is one of the sacrifices all the migrants have to face. Missed the ill parents, relatives and family members. Sometimes even missed the funerals.

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File:Stomach diagram.svg

File:Illu stomach.jpg

* 6. Cardia

File:Illu stomach2.jpg

File:Gray1046.svg

Stomach cancer

Stomach or gastric cancer can develop in any part of the stomach and may spread throughout the stomach and to other organs; particularly the esophagus, lungs and the liver. Stomach cancer causes about 800,000 deaths worldwide per year.[1]

Epidemiology

Stomach cancer is the fourth most common cancer worldwide with 930,000 cases diagnosed in 2002.[2] It is a disease with a high death rate (~800,000 per year) making it the second most common cause of cancer death worldwide after lung cancer.[1] It is more common in men and in developing countries.[2][3]

It represents roughly 2% (25,500 cases) of all new cancer cases yearly in the United States, but it is more common in other countries. It is the leading cancer type in Korea, with 20.8% of malignant neoplasms.

Metastasis occurs in 80-90% of individuals with stomach cancer, with a six month survival rate of 65% in those diagnosed in early stages and less than 15% of those diagnosed in late stages.

One in a million people under the age of 55 seeking medical attention for indigestion have stomach cancer [4] and one in fifty of all ages seeking medical attention for burping and indigestion have stomach cancer.[5] Out of 10 million people in the Czech Republic, only 3 new cases of stomach cancer in people under thirty years of age in 1999 were diagnosed.[6] Other studies show that less than 5% of stomach cancers occur in people under 40 years of age with 81.1% of that 5% in the age-group of 30 to 39 and 18.9% in the age-group of 20 to 29.[7]

Etiology

Infection by Helicobacter pylori is believed to be the cause of most stomach cancer while autoimmune atrophic gastritis, intestinal metaplasia and various genetic factors are associated with increased risk levels. It is not currently believed that diet has any role to play.[8]

In more detail, H. pylori is the main risk factor in 65–80% of gastric cancers, but in only 2% of such infections.[9] Approximately ten percent of cases show a genetic component.[10] In Japan and other countries bracken consumption and spores are correlated with incidence of stomach cancer, though causality has yet to be established.[11]

Gastric cancer shows a male predominance in its incidence as up to three males are affected for every female. Estrogen may protect women against the development of this cancer form.[12] A very small percentage of diffuse-type gastric cancers (see Histopathology below) are thought to be genetic. Hereditary Diffuse Gastric Cancer (HDGC) has recently been identified and research is ongoing. However, genetic testing and treatment options are already available for families at risk.[13]

Some researchers [14] showed a correlation between Iodine deficiency or excess, iodine-deficient goitre and gastric cancer; a decrease of the incidence of death rate from stomach cancer after implementation of the effective I-prophylaxis was reported too.[15] The proposed mechanism of action is that iodide ion can function in gastric mucosa as an antioxidant reducing species that can detoxify poisonous reactive oxygen species, such as hydrogen peroxide.

Symptoms

Endoscopic image of linitis plastica, a type of stomach cancer where the entire stomach is invaded, leading to a leather bottle-like appearance with blood coming out of it.

Stomach cancer is often asymptomatic or causes only nonspecific symptoms in its early stages. By the time symptoms occur, the cancer has generally metastasized to other parts of the body, one of the main reasons for its poor prognosis. Stomach cancer can cause the following signs and symptoms:

Early

  • Indigestion or a burning sensation (heartburn)
  • Loss of appetite, especially for meat

Late

These can be symptoms of other problems such as a stomach virus, gastric ulcer or tropical sprue and diagnosis should be done by a gastroenterologist or an oncologist.

Diagnosis

To find the cause of symptoms, the doctor asks about the patient’s medical history, does a physical exam, and may order laboratory studies. The patient may also have one or all of the following exams:

  • Gastroscopic exam is the diagnostic method of choice. This involves insertion of a fibre optic camera into the stomach to visualize it.
  • Upper GI series (may be called barium roentgenogram)
  • Computed tomography or CT scanning of the abdomen may reveal gastric cancer, but is more useful to determine invasion into adjacent tissues, or the presence of spread to local lymph nodes.

Abnormal tissue seen in a gastroscope examination will be biopsied by the surgeon or gastroenterologist. This tissue is then sent to a pathologist for histological examination under a microscope to check for the presence of cancerous cells. A biopsy, with subsequent histological analysis, is the only sure way to confirm the presence of cancer cells.

Various gastroscopic modalities have been developed to increased yield of detect mucosa with a dye that accentuates the cell structure and can identify areas of dysplasia. Endocytoscopy involves ultra-high magnification to visualize cellular structure to better determine areas of dysplasia. Other gastroscopic modalities such as optical coherence tomography are also being tested investigationally for similar applications.[16]

A number of cutaneous conditions are associated with gastric cancer. A condition of darkened hyperplasia of the skin, frequently of the axilla and groin, known as acanthosis nigricans, is associated with intra-abdominal cancers such as gastric cancer. Other cutaneous manifestations of gastric cancer include tripe palms (a similar darkening hyperplasia of the skin of the palms) and the sign of Leser-Trelat, which is the rapid development of skin lesions known as seborrheic keratoses.[17]

StagingIf cancer cells are found in the tissue sample, the next step is to stage, or find out the extent of the disease. Various tests determine whether the cancer has spread and, if so, what parts of the body are affected. Because stomach cancer can spread to the liver, the pancreas, and other organs near the stomach as well as to the lungs, the doctor may order a CT scan, a PET scan, an endoscopic ultrasound exam, or other tests to check these areas. Blood tests for tumor markers, such as carcinoembryonic antigen (CEA) and carbohydrate antigen (CA) may be ordered, as their levels correlate to extent of metastasis, especially to the liver, and the cure rate.

Staging may not be complete until after surgery. The surgeon removes nearby lymph nodes and possibly samples of tissue from other areas in the abdomen for examination by a pathologist.

TNM staging is used

Treatment

Like any cancer, treatment is adapted to fit each person’s individual needs and depends on the size, location, and extent of the tumor, the stage of the disease, and general health. Cancer of the stomach is difficult to cure unless it is found in an early stage (before it has begun to spread). Unfortunately, because early stomach cancer causes few symptoms, the disease is usually advanced when the diagnosis is made. Treatment for stomach cancer may include surgery, chemotherapy, and/or radiation therapy. New treatment approaches such as biological therapy and improved ways of using current methods are being studied in clinical trials.

 Surgery

Surgery is the most common treatment and is the only hope of cure for stomach cancer. The surgeon removes part or all of the stomach, as well as the surrounding lymph nodes, with the basic goal of removing all cancer and a margin of normal tissue. Depending on the extent of invasion and the location of the tumor, surgery may also include removal of part of the intestine or pancreas. Tumors in the lower part of the stomach may call for a Billroth I or Billroth II procedure. Endoscopic mucosal resection (EMR) is a treatment for early gastric cancer (tumor only involves the mucosa) that has been pioneered in Japan, but is also available in the United States at some centers. In this procedure, the tumor, together with the inner lining of stomach (mucosa), is removed from the wall of the stomach using an electrical wire loop through the endoscope. The advantage is that it is a much smaller operation than removing the stomach. Endoscopic submucosal dissection (ESD) is a similar technique pioneered in Japan, used to resect a large area of mucosa in one piece. If the pathologic examination of the resected specimen shows incomplete resection or deep invasion by tumor, the patient would need a formal stomach resection.

Surgical interventions are currently curative in less than 40% of cases, and, in cases of metastasis, may only be palliative.

A gastrectomy is a partial or full surgical removal of the stomach.

Indications

Gastrectomies are performed to treat cancer and perforations of the stomach wall.

In severe duodenal ulcers it may be necessary to remove the lower portion of the stomach called the pylorus and the upper portion of the small intestine called the duodenum. If there is a sufficient portion of the upper duodenum remaining a Billroth I procedure is performed, where the remaining portion of the stomach is reattached to the duodenum before the bile duct and the duct of the pancreas. If the stomach cannot be reattached to the duodenum a Billroth II is performed, where the remaining portion of the duodenum is sealed off, a hole is cut into the next section of the small intestine called the jejunum and the stomach is reattached at this hole. As the pylorus is used to grind food and slowly release the food into the small intestine, removal of the pylorus can cause food to move into the small intestine faster than normal, leading to gastric dumping syndrome.

Polya’s operation

A type of posterior gastroenterostomy which is a modification of the Billroth II operation. Resection of 2/3 of the stomach with blind closure of the duodenal stump and retrocolic anastomosis of the full circumference of the open stomach to jejunum

History

The first successful gastrectomy was performed by Theodor Billroth in 1881 for cancer of the stomach.

Historically, gastrectomies were used to treat peptic ulcers.[1] These are now usually treated with antibiotics, as it was recognized that they are usually due to Helicobacter pylori.

In the past a gastrectomy for peptic ulcer disease was often accompanied by a vagotomy, to reduce acid production. Nowadays, this problem is managed with proton pump inhibitors.

See also

References

  1. ^ E. Pólya:Zur Stumpfversorgung nach Magenresektion. Zentralblatt für Chirurgie, Leipzig, 1911, 38: 892-894.

Chemotherapy

The use of chemotherapy to treat stomach cancer has no established standard of care. Unfortunately, stomach cancer has not been especially sensitive to these drugs until recently, and historically served to palliatively reduce the size of the tumor and increase survival time. Some drugs used in stomach cancer treatment include: 5-FU (fluorouracil), BCNU (carmustine), methyl-CCNU (Semustine), and doxorubicin (Adriamycin), as well as Mitomycin C, and more recently cisplatin and taxotere in various combinations. The relative benefits of these drugs, alone and in combination, are unclear.[18] Scientists are exploring the benefits of giving chemotherapy before surgery to shrink the tumor, or as adjuvant therapy after surgery to destroy remaining cancer cells. Combination treatment with chemotherapy and radiation therapy is also under study. Doctors are testing a treatment in which anticancer drugs are put directly into the abdomen (intraperitoneal hyperthermic chemoperfusion). Chemotherapy also is being studied as a treatment for cancer that has spread, and as a way to relieve symptoms of the disease. The side effects of chemotherapy depend mainly on the drugs the patient receives.

Radiation therapy

Radiation therapy (also called radiotherapy) is the use of high-energy rays to damage cancer cells and stop them from growing. When used, it is generally in combination with surgery and chemotherapy, or used only with chemotherapy in cases where the individual is unable to undergo surgery. Radiation therapy may be used to relieve pain or blockage by shrinking the tumor for palliation of incurable disease

Multimodality therapy

While previous studies of multimodality therapy (combinations of surgery, chemotherapy and radiation therapy) gave mixed results, the Intergroup 0116 (SWOG 9008) study[19] showed a survival benefit to the combination of chemotherapy and radiation therapy in patients with nonmetastatic, completely resected gastric cancer. Patients were randomized after surgery to the standard group of observation alone, or the study arm of combination chemotherapy and radiation therapy. Those in the study arm receiving chemotherapy and radiation therapy survived on average 36 months, compared to 27 months with observation.

From Wikipedia, the free encyclopedia

Stage II Gastric Cancer

Current Clinical Trials

Note: Some citations in the text of this section are followed by a level of evidence. The PDQ editorial boards use a formal ranking system to help the reader judge the strength of evidence linked to the reported results of a therapeutic strategy. (Refer to the PDQ summary on Levels of Evidence for more information.)

Standard treatment options:

One of the following surgical procedures: Distal subtotal gastrectomy (if the lesion is not in the fundus or at the cardioesophageal junction).

Proximal subtotal gastrectomy or total gastrectomy (if the lesion involves the cardia).

Total gastrectomy (if the tumor involves the stomach diffusely or arises in the body of the stomach and extends to within 6 cm of the cardia).

Regional lymphadenectomy is recommended with all of the above procedures. Splenectomy is not routinely performed.[1]

Postoperative chemoradiation therapy.[2]

Perioperative chemotherapy.[3]

Surgical resection with regional lymphadenectomy is the treatment of choice for patients with stage II gastric cancer.[1] If the lesion is not in the cardioesophageal junction and does not diffusely involve the stomach, subtotal gastrectomy is the procedure of choice. When the lesion involves the cardia, proximal subtotal gastrectomy or total gastrectomy may be performed with curative intent. If the lesion diffusely involves the stomach, total gastrectomy and appropriate lymph node resection may be required. The role of extended lymph node (D2) dissection is uncertain [4] and in some series is associated with increased morbidity.[5,6]

Postoperative chemoradiation therapy may be considered for patients with stage II gastric cancer. A prospective multi-institution phase III trial (INT-0116) evaluating postoperative combined chemoradiation therapy versus surgery alone in 556 patients with completely resected stage IB to stage IV (M0) adenocarcinoma of the stomach and gastroesophageal junction reported a significant survival benefit with adjuvant combined modality therapy.[2][Level of evidence: 1iiA] With a median follow-up of 5 years, median survival was 36 months for the adjuvant chemoradiation therapy group as compared to 27 months for the surgery-alone arm (P = .005). Three-year overall survival (OS) and relapse-free survival rates were 50% and 48%, respectively, with adjuvant chemoradiation therapy versus 41% and 31%, respectively, for surgery alone (P = .005).The rate of distant metastases was 32% for the surgery-alone arm and 40% for the chemoradiation therapy arm. Because distant disease remains a significant concern, the aim of the current Cancer and Leukemia Group B study (CALGB-80101) is to augment the postoperative chemoradiation regimen used in INT-0116.[7] Neoadjuvant chemoradiation therapy remains under clinical evaluation such as in the SWOG-S0425 and RTOG-9904 trials.[8]

Investigators in Europe evaluated the role of preoperative and postoperative chemotherapy without radiation therapy.[3] In the randomized phase III trial (MRC-ST02), patients with stage II or higher adenocarcinoma of the stomach or of the lower third of the esophagus were assigned to receive three cycles of epirubicin, cisplatin, and continuous infusion fluorouracil (ECF) before and after surgery or to receive surgery alone. Compared with the surgery group, the perioperative chemotherapy group had a significantly higher likelihood of progression-free survival (hazard ratio [HR] for progression, 0.66; 95% confidence interval [CI], 0.53–0.81; P < .001) and of OS (HR for death, 0.75; 95% CI, 0.60–0.93; P = .009). Five-year OS was 36.3%, 95% CI, 29 to 43 for the perioperative chemotherapy group and 23%, 95% CI, 16.6 to 29.4 for the surgery group.[3][Level of evidence: 1iiA]

Complications

Total gastrectomy and its early postoperative complications in gastric cancer

INTRODUCTION
The incidence of gastric cancer is declining
in the west, as well as in Vojvodina and
Yugoslavia (1). However, it seems, that decline
is due to the drop of incidence of the intestinal
type of gastric cancer. On the contrary, incidence
of the diffuse type of cancer is increasing
or at least remaining the same. The incidence of
the gastric cancers located proximaly in stomach
is increasing (2). Principal intention of the operation
for gastric cancer is to remove the tumor,
to secure healthy edges of resection and to
restorate the digestive tube. Potential multilocularity
of tumor (3), submucosal spreading away
from visible edge of tumor as well as attempts to
secure healthy proximal resection line, engage
total gastrectomy in the treatment of tumors,
even located distally. Once associated with high
mortality, it is today standard operation for cancer
treatment, equally important as subtotal
resection.
At the Institute of Oncology Sremska
Kamenica, Novi Sad, the largest hospital for
treating the malignancies in the province of
Vojvodina, which is the northern province of
Yugoslavia with 2013890 inhabitans according
to the 1991 census, total gastrectomy was seldom
performed before 1990. The first operation
was done in 1986, followed by four other operations
till 1990, performed by two surgeons, with
mortality of 40%. Since the beginning of 1990,
after adopting a new approach of operative
treatment which engaged different treatment of
two different histologic types of gastric cancer
after LaurenÕs classification (4), and appearance
after Borrmann (5), we had 76 operations during
the period from the 1st of January 1990 till the
1st of June 1997. The operations were conducted
by eight surgeons without stapling devices. The
complications and mortality of the procedure
are reviewed accentuation having been put on
the postoperative complications which ended
fatally.
MATERIALS AND
METHODS
Retrograde study using medical documentation
and histologic findings covers the period
commencing on 1st of January 1990 and ending
on 30th of June 1997. Patients, included in the
study, were the patients with histologic evidence
of gastric cancer, who due to the type or
location of the tumor were submitted to total
gastrectomy (TG) at the Institute of Oncology in
Sremska Kamenica. The operation was performed
in 76 cases. There was no exclusion of
the operated patients. No statistic analysis was
employed.
Indications for total gastrectomy were: any
location of gastric carcinoma of Borrmann 4 type
or of diffuse type of gastric cancer. Intestinal
and mixtus types of gastric cancer of Borrmann
3 type when situated in proximal 5 cm of stomach
and intestinal and mixtus types of gastric
cancer of Borrmann 1 or 2 type when placed in
proximal 2 cm of stomach. Resection was abandoned
in cases of: anesthesiologic contraindications,
massive distant metastases, carcinosis of
peritoneum and ascit; and in patients whose
91
‚ 2000, Institute of Oncology Sremska Kamenica,Yugoslavia
Address correspondence to: Prim. Dr Nikola Budi¹in,
Department of Surgery, Institute of Oncology Sremska
Kamenica, 21204 Sremska Kamenica, Institutski put 4,
Yugoslavia
The manuscript was received: 04. 04. 2000.
Provisionally accepted: 19. 04. 2000.
Accepted for publication: 15. 05. 2000.
ABSTRACT
Background: The study shows operative results and complications occuring in the first 30
days after total gastrectomy because of stomach cancer.
Materials and methods: Retrograde analysis was performed using medical documentation
and histologic findings of 76 patients after total gastrectomy done between 1990 and 1997.
Mortality and postoperative complications were analysed. Complications were sorted as specific
and non-specific. All operations were done either for intestinal gastric cancer located in proximal
stomach or for diffuse stomach cancer. All anastomoses were sewn by hand. Eight surgeons were performing
the operations.
Results: There were 43 male and 33 female patients. Postoperative mortality was 14.4%. Most frequent
complications were: dehiscence of oesophago-jejuno anastomosis, which happened in 15.8% of
operated patients, postoperative temperature without apparent infection in 5.2%, thrombophebitis in
5.2%. Pneumothorax with a frequency of 3.9%, hepatic necrosis in one patient 1.3%, and perforation of
jejunal loop with nasogastric tube in 1.3%, which all ended fatally contributed to the relatively high
mortality. Mean postoperative intrahospital treatment lasted 12.3 days. Dehiscence of oesophagoentero-
anastomosis, resulted in generalised peritonitis in 66.6%. Six patients succumbed as a consequence,
while two survived with subphrenic and intraansal abscesses. Pneumothorax in combination
with total gastrectomy was always fatal.
Conclusion: Routine use of stapling surgery, sub-specialisation in surgery and better early
intensive care monitoring and treatment could improve mortality rate.
Key words: Gastric cancer; Surgery; Resection; Gastrectomy; Complications
Archive of Oncology 2000,8(3):91-4‚2000, Institute of Oncology Sremska Kamenica, Yugoslavia
Archive of Oncology 2000;8(3):91-4.
Original article
UDC:616.33-006:616-089.8:616-06
Nikola BUDI©IN
Ivan MAJDEVAC
Milan BREBERINA
Branimir GUDURIÆ
DEPARTMENT OF SURGERY, INSTITUTE OF ONCOLOGY
SREMSKA KAMENICA, SREMSKA KAMENICA, YUGOSLAVIA
Total gastrectomy and its early
postoperative complications in gastric
cancer
performance status was 30% or less, using
Karnofsky (6) index. Patients with preoperatively
diagnosed involved distal esophagus were
transferred to Department of Thoracic Surgery
at the Institute for chest diseases for further
treatment and were not included in this study.
Mortality was defined as the lethal outcome
during the operation and first thirty postoperative
days. Complications have also been calculated
if aroused in the same period. Complications
that have led to lethality were separately
described and discussed.
Patients were admitted at the Department of
Surgery with known diagnosis, positive histologic
findings after gastroscopy, with description
of tumor after Borrmann. Their histologic findings
included Laurens subdivision on diffuse,
intestinal or mixtus type of gastric cancer.
Routine laboratory findings, blood group, blood
sample, urinalysis, chest X-ray, EKG, ultrasonography
of liver and in female patients gynecological
findings were also required. Histology of
resected specimens used TNM system while
stages were determined by United international
gastric cancer staging classification system (7).
The operations were conducted in general
anaesthesia through abdominal approach. Each
operation included at least gastrectomy, extirpation
of both omentums, accompanied with lymphadenectomy
either D1 or D2. In case of perigastric
spread of the disease combined resection
was employed, with removal of adjacent organs
or part of organs. Reconstruction oesophagojejunostomy
was performed in three different
manners, namely via Omega loop of jejunum, by
the means of roux loop, and/or interposition of
jejunal loop without separation from continuity
of intestine – known as TomodaÕs method.
Method of reconstruction depended on preferance
of the operating surgeon. There were eight
surgeons performing the operations, none of
who used only one method of reconstruction. All
anastomoses were hand sewn. Postoperatively,
until the peristaltic waves, patients were attented
by the personnel of the intesive care unit.
RESULTS
Total gastrectomy was performed in 76
cases. There were 43 males and 33 female
patients, aged between 28 and 73 years, mean
age having been 54.6 years. Both male and
female ratio was 1.3. Postoperative histology
showed that there were 5 early gastric carcinomas
(7% of cancers), and 66 advanced cancers
(93%). Fifteen out of these were of intestinal type,
49 of diffuse type and 8 of mixed type.
Remaining four cases remained unspecified.
Thirty three of patients presented with infiltration
of tumor to the surrounding structures – T4
tumor, followed by 19 patients with tumor
invading serosa – T3, 12 patients of tumor infiltrating
gastric wall but not serosa – T2, and 8
cases of T1. Majority of patients had positive N2
lymph nodes, 31 patient, 25 patients had positive
only N1 lymph nodes, while 16 patients had negative
lymph nodes. Seventy patients were without
metastasis while 6 had them. Ten patients
were in Stage I of the disease, 9 in stage II, 22 in
stage III and 31 in stage IV. In four cases stage
was not determined, due to the incomplete histology.
Reconstruction included esophagojejunostomy
via Roux en Y loop in 41 case, after
TomodaÕs method in 31 cases and using Omega
loop in 4 cases. Forty two cases were accompanied
by D2 lymphadenectomy while 34 patients
underwent D1. All anastomoses were hand
sewn. Extended resections were performed in 21
cases, 4 patients with resection of the colon and
17 patients with splenectomy and dissection of
splenic port with distal pancreatectomy. Positive
lymph nodes in splenic port, verified by histology,
were found in just one case out of 17 cases
after the splenectomies (5.8%).
There were eleven postoperative lethal outcomes,
which gives overall mortality of 14.4%.
Mean intrahospital treatment lasted 17.29;
posoperatively 12.28 days (range from 2 to 43
days, SD = 5.76).
Complications
Complications were calculated for the first
30 postoperative days, during the intrahospital
postoperative period. They were regarded
either as specific complications, which resulted
as the consequence of gastric operation – total
gastrectomy, or nonspecific, common after any
surgery. All nonspecific complications were
treated as expected, except pneumothorax
where drainage of thoracic cage was employed
in addition of intensive care measures.
Pancreatic fistulas were also treated conservatively,
as well as the case of hepatic necrosis
and some of the cases of dehiscence of
oesophagojejunal anstomosis, while all recognized
cases of peritonitis were treated by reoperations.
Complications which ended lethally
The most frequent complication after the
resection was dehiscence of oesophagojejunostomy.
It occurred in 12 patients (15.8) some of
them were recognized with routine peroral contrast
given on the 4th postoperative day, while
the others, presented with clear clinical manifestations,
were confirmed by the x-ray. Four out of
these twelve cases (33.3%) were minor leaks,
clinically silent, accompanied only with prolonged
absence of peristaltic waves, and slightly
raised pulse in one patient. Prolonged nasogastric
suction, intravenous fluids, antibiotics, total
parenteral nutrition and careful intensive monitoring,
was the manner of treatment in these
patients. All four patients recuperated completely.
Eight other patients (66.6%) developed
generalized peritonitis, six of which succumbed
to the illness. Remaining two patients survived,
one after the conservative therapy, with local-
92
Budi¹in N.
‚ 2000, Institute of Oncology Sremska Kamenica,Yugoslavia
Table 1. Main clinical, pathological and surgical
variables in patients undergoing total gastroctomy
Table 2. Nonspecific early postgastrectomy complications,
incidence and mortality
Table 3. Specific early postgastrectomy complications,
incidence and mortality
ized subphrenic abscesses as a consequence, the
other after the reoperation. Since all patients had
abdominal drains inserted at the conclusion of
operation, quantity of drain content was crucial
for the decision for further treatment.
Dehiscence was treated conservatively if drain
content was less than 500 ml daily, or reoperated
if it was more. Conservative treatment
included insertion of central venous line, control
of the acidobase, fluid and electrolite balance,
antibiotics, cardiotonics in elderly and total parenteral
nutrition. At the reoperation owersuing
of leekage or resture of the anastomosis was
done. However these attempts resulted inpoor
effect. Five out of six patients who succumbed
were reoperated, while one was conservatively
treated. Overall mortality for this complication
including leaks was 50%, it was 75% for major
desiscences, while mortality for reoperated
patients reached 83.3%. Major leaks, treated
conservatively, had mortality of 50%, while all
minor ones survived.
Pneumothorax. Two cases resulted with the
insertion of subclavian catheter at the conclusion
of the operation. The third one arouses
from rupture of emphysematous bulla during
the operation. Increased resistence to ventilation
accompanied by hypoxia, tachicardia and drop
of arterial tension was observed in this case.
Diagnosis was made in recovery room after the
x-ray was taken, few hours after the operation.
Although all three cases were recognized early
and promptly treated with underwater sealed
drainage, all three patients succumbed.
Reexpansion of the lung occurred partially
just in one case while two remaining patients
died without it. Airways plugged with mucus
combined with weakened respiratory effort
could have contributed to failed reexpansion.
Cardio-respiratory insufficiency without any
traces of dehiscence of the anastomosis was
indicated as the cause of demise at autopsy.
Atelectasis combined with pneumothorax was
evident in one case.
Hepatic necrosis resulted from unintentional
ligation of abberant common hepatic artery.
Patient presented with jaundice on the third
postoperative day, elevated serum transaminase
levels, leukocitosis, fever combined with
abdominal pain, hepatomegaly and prolonged
lacking of peristalsis. This was understood as
postoperative toxic hepatitis. No surgical reoperation
was attempted, patient remained in
intensive unit and was treated conservatively.
Complication ended with demise on the 9th
postoperative day. Common hepatic artery was
found ligated, on autopsy which aroused from
left gastric artery. Artery was not recognized in
the course of operation, due to the enlarged and
melted lymph nodes around celiac trunk.
Perforation of jejunal loop with nasogastric
tube showed up on the fifth postoperative day
with the signs of generalized peritonitis.
Metabolic acidosis accompanied with tachicardia,
localized tenderness of abdomen and lack
of peristaltic waves. Content of abdominal drain
bag, was not conclusive. Nasogastric suction,
which was put in place during the operation
with the tip of the tube in jejunal loop, and since
installation, was left undisturbed, showed
diminished volume in the last 24 hours prior to
clinical signs. Intermittent negative pressure
through nasogastric tube, was employed during
the four days preceding the perforation, with
intermittent negative pressure of 10 mm of
water column applied, 2 hours on followed by
two hors off. Nasogastric tube was neither
moved nor rotated in, the postoperative period.
Contrast peroral radiography showed spilling
of contrast in abdominal cavity. Patient was submitted
to reoperation with suspected dehiscence
of esophagojejuno anastomosis.
Intraoperative finding showed anastomosis
without dehiscence, as well as properly closed
duodenum. Drain was occluded with fibrin and
did not function. Peritoneal cavum was soiled
with intestinal content. The perforation on intact
efferent jejunal loop was found 15 cm from
anastomosis with esophagus, with nasogastric,
elastic tube protruding through intestine in
abdominal cavity.
During the reoperation, the abdomen was
washed out, perforation on the intestine was
oversued, abdomen drained. Intensive antibiotic
therapy combined with correction of acidosis,
and hypovolemia followed in recovery room.
Despite these measures, patient did not recover.
Septic shock was ascribed as cause of death. No
abnormality was found in the structure of intestine
wall regarding anatomy or histology, on
autopsy.
DISCUSSION
Most of the authors advocated combined
resection of spleen and distal pancreas in proximally
sited gastric cancer with TG, in order to
achieve better clearance of lymph nodes in
splenic hilus. On the other hand, there is an
increasing number of recent studies that doubt
this approach, having in mind survival, morbidity,
mortality and postoperative quality of life
(8-11). In our seventeen cases with splenectomy
and distal pancretectomy done, we had two
cases of postoperative pancreatic fistulas
(11.8%), which considerably prolonged hospital
stay, while the incidence of positive histologic
lymph nodes in splenic hilus was only 5.9%.
This changed our policy toward the extension of
operation, which was serially done for proximal
sited cancers during the first two years, to apply
it later, just in cases when tumor is situated
proximally and had a palpable lymph nodes in
splenic hilus, or directly invaded or was adherent
with spleen.
Anatomic anomally regarding origin of
common hepatic artery from the left gastric
artery occurs in less than 1% of population (12).
Few authors dealt with arterial aberrations and
postgastrectomy complications. Most of them
(13,14) advise preoperative angiography to
exclude this malformation. Procedures of reconstruction
of hepatic artery during gastric resection
were described (15). In our operation,
which was conducted without preoperative
angiography and which included D2 lymphadenectomy
with extirpation of lesser omentum
under hemostats, with enormously
enlarged lymph nodes, the anomally remained
unrecognized. Angiography as the routine preoperative
finding is unfortunately unaffordable
in Yugoslavia, bearing in mind the costs of the
procedure, prolongation of the intrahospital
stay and the possibility of misinterpretation of
the findings.
Perforation of the jejunal loop, away from
suture line on intact intestine led us to change
the approach to the postoperative nasogastric
tube. Before the incident, the tube was regarded
as the stent as well as the decompression device,
which was connected to the intermittent negative
pressure. Once installed, during the operation,
it was neither moved, nor touched for at
93
Total gastrectomy and postoperative complications
‚ 2000, Institute of Oncology Sremska Kamenica,Yugoslavia
Figure 1. Ligature tied around common arousal of
left gastric artery and common hepatic artery
Figure 2. Perforation of jejunom with the tip of the
nasogastric tube
least four postoperatie days, until control radiography.
After this complication, we accepted
the policy of passive suction with the irrigation
of the tube with 20 ccm of saline twice a day
combined with mild rotation. This, we believe,
reduces the pressure on the same point, and precludes
the aspiration and sticking of the intestinal
mucosa which could arise possible ishaemia.
We did not find connection in literature
between perioperatively aroused pneumothorax
and total gastrectomy. Most of the literature
deals with preoperatively diagnosed respiratory
diseases and their influence on mortality. There
are authors who suggest that preoperative peak
expiratory flow rate, in elderly patients (16) and
preoprative Pa, O2 are significant findings in
preclusion of postoperative pulmonary complications.
These are not usual preoperative findings
in our hospital. Preoperatively diagnosed
respiratory disease was reported to increase
morbidity (17,18). In our experience, only one
case out of three had preoperative pulmonal disease
– emphysema. Two other cases were connected
with the installation of subclavian
venous catheter, done in general anesthesia at
the conclusion of the operation. Since this is not
an unusual medical intervention, it is curious
that no other similar accidents have been reported.
All three patients succumbed contributing to
the mortality of this complication 100% in our
experience.
CONCLUSION
In the last two decades Japanese authors have
put new frontiers regarding resectability, and
survival in the treatment of gastric cancer.
Mortality has dropped after TGtg to less than
2% in Japan, but remained between 8-20% in
various West European, American and South
African clinics with tendency of further declining.
Mortality could be reduced with the experience,
and in subspecialised clinics as has already
been reported (19). It should be said, that there
is no particular person regarding surgeons,
anesthesiologists or parhologists dealing only
with gastric cancer in Vojvodina. We have managed
to decrease mortality from 40% at the start
of performing this procedure to acceptible
14.6%, 1990 being the breaking point. An
increased number of operations have contributed
to this, as well as introduction of new
generation of surgeons.
Two unusual surgical complications, perforation
of jejunal loop and hepatic necrosis, have
thought us the lesson to be more careful in the
intensive care unit with the nasogastric tube as
well as to be aware of possible vascular aberrations.
Connection between intraoperative pneumothorax
and total gastrectomy, concerning
high mortality, deserves further investigation.
With better preoperative diagnostics, that
would include barium meal, endoscopic ultrasound,
CT regarding the staging of tumor, and
better preoperative pulmonary evaluation, as
well as with better intraoperative and postoperative
monitoring and care, we could further on
decrease mortality after total gastrectomy.
Intraoperative improvements combined with
selection of operating team, and introducing stapling
surgery, would certainly lead to better
survival.
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for carcinoma. Arch Surg 1991;126:356-64.
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Fremgen AM. Role of splenectomy in gastric cancer surgery:
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10. Otsuji E, Yamaguchi T, Sawai K, Ohara M, Takahashi T.
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11. Roukos DH. Current advances and changes in treatment
strategy may improve survival and quality of life in patients
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12. Lippert H, Pabst R. Hepatic arteries. In: Arterial variation
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13. Okano S, Sawai K, Taniguchi K, Takahashi K. Aberrant left
hepatic artery arising from the left gastric artery and liver
function after radical gastrectomy for gastric cancer. World J
Surg 1993;17:70-4.
14. Hemming AW, Finley RJ, Evans KG, Nelems B, Fradet G.
Esophagogastrectomy and the variant left hepatic artery. Ann
Thorac Surg 1992;54:166-8.
15. Takenaka H, Iwase K, Ohshima S, Hiranaka T. A new
technique for the resection of gastric cancer: modified
Appleby procedure with reconstruction of hepatic artery.
World J Surg 1992;16:947-51.
16. Fan ST, Lau WY, Yip WC, Poon GP, Yeung C, Lam WK, et
al. Prediction of postoperative pulmonary complications in
oesophagogastric cancer surgery. Br J Surg 1987;74:408-10.
17. Wu CW, Hsieh MC, Lo SS, Wang LS, Hsu WH, Lui WY, et
al. Morbidity and mortality after radical gastrectomy for
patients with carcinoma of the stomach. J Am Coll Surg
1995;181:26-32.
18. Frey P. Respiratorishe Insuffizienz und Operabilitat.
Schweiz Med Wochenschr 1979;109:1562-4.
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Budi¹in N.
‚ 2000, Institute of Oncology Sremska Kamenica,Yugoslavia

 

 

 

 

                        

 

 

  

 

Early complications following total gastrectomy for gastric cancer*

Nikola Budiin, MD, Prim.dr 1 *, Evica Budiin, MD, Mr sci med 2, Andrija Golubovi, MD, Mr sci med 1
1Institute of Oncology, Department of Surgery, University of Novi Sad, Vojvodina, Yugoslavia
2Institute of Chest and Pulmonary Diseases, University of Novi Sad, Vojvodina, Yugoslavia
email: Nikola Budiin (nikbu@Eunet.yu)

*Correspondence to Nikola Budiin, Institute of Oncology, Department of Surgery, University of Novi Sad, 21204 Sremska Kamenica, Vojvodina, Yugoslavia.

**Abstract was accepted and paper was presented at the 1998 International Cancer Conference of the UICC.

Keywords
gastric cancer; surgery; resection; gastroectomy; complications; mortality; morbidity; pneumothorax
Abstract
Background
The study shows operative results with complications occurring in first 30 days after total gastrectomy for stomach cancer.
Methods:
A retrospective analysis was performed using medical documentation and histological findings for 76 patients after total gastrectomy was done between 1990 and 1997. Mortality and postoperative complications were analyzed. Complications were sorted as specific and nonspecific. All operations were performed either for intestinal gastric cancer located in proximal stomach or for diffuse stomach cancer. All anastomoses were hand sewn.
Results:
There were 43 male and 33 female patients. Postoperative mortality was 14.4%. The most frequent complications were dehiscence of the oesophago-jejunal anastomosis in 15.8% of operated patients, postoperative temperature without apparent infection in 5.2%, thrombophlebitis in 5.2%, pneumothorax in 3.9%, hepatic necrosis in one patient (1.3%), and perforation of jejunal loop with nasogastric tube in another (1.3%) ended fatally. The average postoperative intra-hospital treatment lasted 12.3 days. Dehiscence of the oesophago-enteric anastomosis, resulted in generalized peritonitis in 66.6%. Six patients succumbed as a consequence, while two survived with subphrenic and interenteric abscesses. Pneumothorax in combination with total gastrectomy was always fatal.
Conclusions:
Routine use of stapling surgery, subspecialization in surgery, and better early intensive care monitoring and treatment could reduce the mortality rate. J. Surg. Oncol. 2001; 77:35-41. © 2001 Wiley-Liss, Inc.

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