Jakarta Digestive Week 7-8 December 2007

Gastric cancer surgery

Departement of Surgery,School of
Medicine,Andalas University Padang
,West Sumatra Indonesia
Jakarta Digestive Week 7-8 December 2007
Introduction (1)
Incidence
-- 2 nd most common cause of cancer
mortality worldwide
-- But 7 th most frequent cause of cancer
death USA ( 11,780 death in 2003)
-- 46/100,000 1930 7/100,000 in men
-- 37/100,000 1930 4/100,000 in women
because : related to diet and food storage
Jakarta Digestive Week 7-8 December 2007
Introduction (2)
Proximal adenocarcinoma more often
Age adjusted death rate 5 /100,000 in USA to
35 /100,000 in Russia.
5 year survival rate 15 %
Improved survival rates in Japan
Overall survival is highly correlated with the
stage presentation .
Unfortunately accurate staging is poorly applied
outside specialized units



Jakarta Digestive Week 7-8 December 2007
Introduction (3)
Accuracy of staging is questionable because
difference survival rate
-- NCDB stage 1 43 %
stage 2 37 %
-- Sp unit stage 1 75-90 %
stage 2 40 50 %
Improved overall survival early stg diagnosis



Jakarta Digestive Week 7-8 December 2007
Risk factors
Nutritional Low fat /protein concumption
-- Salted meat or fish
-- High nitrate consumption
-- High complex-CHO consumption
Enviromental
-Poor food prep.(smoked,salted)
-Lack of refrigeration
-Poor drinking water ,
-Smoking


Jakarta Digestive Week 7-8 December 2007
Risks factors (Cont)
Medical
-- Prior gastric surgery
-- Helicobacter pylori infection
-- Gastric atrophy and gastritis
-- Adenomatous polyps
-- Male gender
Social Low Social Class
Jakarta Digestive Week 7-8 December 2007
Signs symptoms
Abdomial pain
Unexplained weight loss
Anorexia,early satiety
Anemia
Upper GI Bleeding
No one of these is sensitive / specific
Jakarta Digestive Week 7-8 December 2007
Physical Examination
Non specific
Occasionally revealing evidence of
advanced / metastatic disease
abdominal mass,ascites,jaundice
,temporal wasting,Virchow node ,Sister Ma
ry Josep node, mass in pelvic cul de sac
(Blumer Shelf) and Krukenberg tumor
Jakarta Digestive Week 7-8 December 2007
Diagnosis
Typically by EGD
--Good visualization
--determination of size and location
--biopsy and brushing of suspicious lesion
Screening Exam : Endoscopy and contrast
study is not cost effective
Jakarta Digestive Week 7-8 December 2007
Staging
CT Scan Abdomen and Pelvis show
ascites,metastatic spread organ and
lympadenopathy But some understage
failure in detection small metastases
Endoscopy ultrasonography superior to
CT in detecting tumor invasion to other
structures
Laparoscopy : Preop staging in up to 58 %
-- prevent unnecessary laparotomy

Jakarta Digestive Week 7-8 December 2007

Jakarta Digestive Week 7-8 December 2007
Surgery of gastric adenocarcinoma
1. Curative Resection
-- confined to primary and regional lymph
nodes
-- 5-7 cm tissue margins confirmed by fro
zen section
-- To obtain negative margins En bloc
resection of adjacent structure
-- Optimal extent of lymphadenectomy
Jakarta Digestive Week 7-8 December 2007
Jakarta Digestive Week 7-8 December 2007

Jakarta Digestive Week 7-8 December 2007
Subtotal Gastrectomy and
Reconstruction

Jakarta Digestive Week 7-8 December 2007
Subtotal Gastrectomy

Jakarta Digestive Week 7-8 December 2007
Total Gastrectomy and
reconstruction

Jakarta Digestive Week 7-8 December 2007
Roux en Y anastomose

Jakarta Digestive Week 7-8 December 2007
Adjuvant therapy
1.Adjuvant Chemotherapy not consisted benefit ( Clin
Oncol 2002;21:2282)
2.Neoadjuvant Chemoterapy
reduse tumor size ,enhancing chance re-
sectability
Elimination of delayed chemoterapy
3.Postoperative radiotherapy decrease loco-
regional recurrence (remains investaigation )
4.Hyperthermic intraperitoneal chemoperfusion with mitomy
cin C improve long term survival in locally advance pt


Jakarta Digestive Week 7-8 December 2007
Gastric Cancer in Padang,West
Sumatra,Indonesia
Very seldom When compared to
Colorectal Cancers

Based on Pathological lab. of faculty of
medicine ,Andalas University ,Padang
not included in 10 most common cancer
diseases

Jakarta Digestive Week 7-8 December 2007
Distr frequency of malignancy related to site(2000-
2004)in west Sumatra, Pathological base (N=3733)
Organ site Freq Persentage
1.Sexual organ 893 26,48
2.Breast 651 19,30
3.Gastrointestinal 558 16,54
4.Skin 319 9,46
5.RES 319 9,46
6.Thyroid 144 4,27
7.Soft tissue 144 4,27
8.Nasopharing 123 3,65
9.Urinarius tracts 109 3,23
10.Eye 84 2,49
Jakarta Digestive Week 7-8 December 2007

Distribution Frequency of Malignancy 0n pathological base in Padang
,West Sumatra Indonesia (1999)
N0 Site of malignancy Freq Percentage
1 Breast 144 16,20
2 Lymph node 92 10,35
3 Skin 88 9,90
4 Lung 83 9,34
5 Cervix 71 7,99
6 Rectum 61 6,86
7 Ovarium 55 6,19
8 Colon 38 4,27
9 Thyroid 31 3,49
10 Soft Tissue 26 2,92
Jakarta Digestive Week 7-8 December 2007
Tabel. Gastric Adenocarcnoma in Djamil Hospital
,Padang (2004-2006)
Ages(yrs) men
women
Total Persent
31-40 1 1 2 28,57%
41-50 3 - 3 42,86%
51-60 - 1 1 14,29%
61-70 - - - 0 %
71-80 - 1 1 14,29 %
Total 4 3 7 100 %
Jakarta Digestive Week 7-8 December 2007
Jakarta Digestive Week 7-8 December 2007
Macroscopic appearance