Subtotal Gastrectomy and Gastrojejunostomy, Risk factors of Gastrointestinal stromal tumors

Subtotal Gastrectomy and Gastrojejunostomy are surgical procedures performed for conditions like gastric cancer, peptic ulcer disease, or gastric outlet obstruction. Subtotal Gastrectomy is a surgical procedure where a portion of the stomach (usually the distal part) is removed. Gastrojejunostomy is a surgical connection (anastomosis) created between the stomach and the jejunum (a part of the small intestine).

Subtotal Gastrectomy and Gastrojejunostomy

Removal of 80% of the stomach, L.Ns, the gastrohepatic gastrocolic omenta, and the first part of the duodenum.

Subtotal Gastrectomy (STG) is indicated for: lesions of the body and antrum (the distal lesions).

Prognosis

• 5-year survival for STG-25-45%.
• Less morbidity than total gastrectomy.
• No benefit of Total Gastrectomy if margins > 5cm.
• STG is similar to total one except that the Proximal part of the stomach is preserved. Followed by reconstruction and creating anastomosis. (by gastrojejunostomy, billroth II).

Palliative surgery

• For patients with advanced inoperable disease & suffering significant symptoms e.g. obstruction, bleeding.
• Palliative gastrectomy not necessarily to be radical, remove resectable masses & reconstruct (anastomosis/intubation/stenting/recanalization).
• If life expectancy is > 2 ms, palliative gastrectomy is better to be done than palliative GJ.
• For inoperable cases of cardiac tumors: Intubation with a Celestin tube is done to overcome the dysphagia.

Post-operative complications:

• Leakage from the duodenal stump.
• Secondary hemorrhage.
• Nutritional deficiency in the long term.

Chemotherapy (preoperative & postoperative)

• Responds well, but there is no effect on survival.
• Marsden Regimen→ Epirubicin, cisplatin & 5-flurouracil 6 cycles for (3 weeks).
• Response rate: 40%.

Radiotherapy (preoperative 6c potopgive

Postoperative radiotherapy may decrease the recurrence.

Summry

Gastric cancer is one of the leading causes of cancer-related death worldwide, Many patients have inoperable disease at diagnosis or have recurrent disease after resection with curative intent. Gastric cancer is separated anatomically into true gastric adenocarcinomas and gastro-oesophageal junction adenocarcinomas, and histologically into diffuse and intestinal types.

Gastric cancer should be treated by teams of experts from different disciplines, Surgery is the only curative treatment. For locally advanced disease, adjuvant or neoadjuvant therapy is usually implemented in combination with surgery. In metastatic disease, outcomes are poor, with a median survival being around 1 year.

Targeted therapies, such as trastuzumab, an antibody against HER2, and the VEGFR-2 antibody ramucirumab, have been introduced.

Less commen gastric neoplasm

• Gastrointestinal stromal.
• tumour GIST Lymphoma.
• Neuroendocrine tumours – Carcinoid.

Gastrointestinal stromal tumors (GIST):

Mesenchymal neoplasms are derived from the interstitial cells of Cajal (pacemaker cells controlling peristalsis). Larger tumors with a high mitotic rate tend to behave malignantly. The stomach is the commonest site.

Overexpress the c-kit oncogene: Used as a diagnostic aid on tissue.

Treatment: GIST is the only type that has a real systemic medical R/ because of the expression of KIT (tyrosine kinase receptor).

Clinical trials have shown partial response rates in patients treated with Imatinib for advanced, recurrent, or metastatic GISTs. It has been used in the pre-operative R/ to ↓ tumor size before surgical resection.

Gastric lymphoma

All are non-Hodgkin type (B cell mucosa associated with MALT lymphoma).

5% of all primary gastric neoplasm’s.

2 different types of lymphoma:

• Part of systemic lymphoma with gastric involvement (32%).
• Part of the primary involvement of the GIT (MALT Tumors), 50% of those are gastric in nature.

Risk factors:

• H Pylori due to chronic stimulation of the MALT.
• In the early stages of the disease Rx of HP leads to regression of the disease.

The incidence of lymphoma has been on the rise over the past 2 to 3 decades. This increase has been observed in extranodal forms. The most common extranodal site of NHL is the stomach, representing between 30% and 40% of all extranodal lymphomas and 55% and 65% of all gastrointestinal lymphomas. Primary gastric lymphoma (PGL) is a rare tumor, with an incidence of approximately 5% of primary gastric neoplasms.

MALT Lymphoma

Most gastric lymphomas are thought to arise in the mucosa or submucosa from the so-called Mucosa-Associated Lymphoid Tissues (MALT), which usually develop after chronic inflammation induced by H pylori infection.

Clinical presentation:

• Bulky tumor: palpable mass (50%) when discovered versus 25% in adenocarcinoma.
• Symptoms are mild in relation to tumor size, but my present with bleeding & perforation.

Diagnosis

• Barium meal + CT scan (for staging).
• Gastroscopy with biopsy & brush cytology.

Treatment

The modalities of treatment for gastric lymphomas have been a controversial subject.

• Surgery alone.
• Non-surgical treatment with Radiation and Chemotherapy.
• Surgery and Radio-chemotherapy.
• Low-grade lymphoma ⇒ Cyclophosphamide.
• High-grade lymphoma ⇒ Surgical resection

this gives the best results + total abdominal radiation + intra-operative staging (Needle biopsy both hepatic lobes. Celiac & para-aortic LN biopsy, splenectomy if directly invaded) + post-operative chemotherapy (patients with high risks of recurrence). The 5-y survival is 50%.

Gastric Neuroendocrine Tumors-Carcinoid Tumors

Gastric Carcinoids constitute 4% of all gastrointestinal neuro-endocrine tumors (GI-neuroendocrine tumors) and 1% of gastric neoplasms. They originate from the Enterochromaffin- like cells) (ELC cells) in the gastre mucosa.

Carcinoid Tumors are the most common malignant tumor of the appendix, but they are most commonly associated with the small intestine, and they can also be found in the Rectum and Stomach. They have a very slow growth rate compared to most malignant tumors

The majority of these tumors are benign, but metastases to the liver have been repórted in 3-5% of patients. Small tumors can be removed endoscopically, while larger tumors or those demonstrating invasion require surgical excision. Ongoing endoscopic surveillance is required every six months since recurrence remains high.

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