This document provides an overview of the anatomy, blood supply, lymphatic drainage and histology of the esophagus and stomach. It discusses the locations of esophageal and gastric tumors and their associated risk factors. Benign esophageal tumors are rare, accounting for less than 1% of cases, with leiomyomas being most common. Malignant esophageal tumors are usually squamous cell carcinomas in the upper two-thirds and adenocarcinomas in the lower third. Risk factors include smoking, alcohol consumption and Barrett's esophagus. Common clinical features of esophageal cancer include dysphagia, weight loss and cervical lymphadenopathy.

1. OESOPHAGEAL & GASTRIC
TUMORS
DR.MISBAH SARFRAZ

2. ANATOMY
●
The esophagus is a 25-
cm long muscular tube
that connects the pharynx
to the stomach.The
esophagus extends from
the lower border of the
cricoid cartilage (at the
level of the sixth cervical
vertebra) to the cardiac
orifice of the stomach at
the side of the body of the
11th thoracic vertebra.

3. ●
The first constriction is at 15 cm from the upper
incisor teeth, where the esophagus commences
at the cricopharyngeal sphincter; this is the
narrowest portion of the esophagus and
approximately corresponds to the sixth cervical
vertebra
●
The second constriction is at 23 cm from the
upper incisor teeth, where it is crossed by the
aortic arch and left main bronchus
●
The third constriction is at 40 cm from the upper
incisor teeth, where it pierces the diaphragm;
the lower esophageal sphincter (LES) is
situated at this level[1, 2, 3]

4. ●
These measurements are clinically important
for endoscopy and endoscopic surgeries of
the esophagus

5. ●
The esophagus has been subdivided into 3
portions, as follows:
●
The cervical portion extends from the
cricopharyngeus to the suprasternal notch
●
The thoracic portion extends from the
suprasternal notch to the diaphragm
●
The abdominal portion extends from the
diaphragm to the cardiac portion of the
stomach.

6. Blood supply
●
Cervical portion
---INF THYROID
ARTERY
●
Thoracic portion
------- bronchial and
esophageal
branches of the
thoracic aorta
●
Abdominal portion
---ascending
branches of the left
phrenic and left
gastric arteries

7. VENOUS DRAINAGE
●
Venous blood from the esophagus drains into a
submucosal plexus---->blood drains to
periesophageal venous plexus--->Esophageal
veins drain in a segmental way similar to the
arterial supply, as follows:
●
From the cervical esophagus---> the inferior
thyroid vein
●
From the thoracic esophagus,-----> the azygos
veins, hemiazygos, intercostal, and bronchial
veins

8. ●
From the abdominal
portion---->left gastric
vein; the left gastric
vein is a tributary of
the portal system.

9. LYMPHATIC DRAINAGE
Submucosal lymphatic system .The esophagus
has 2 types of lymphatic vessels. A plexus of
large vessels is present in the mucous
membrane, and it is continuous above with the
mucosal lymphatic vessels of pharynx and
below with mucosal lymphatic vessels of gastric
mucosa.
●
The second plexus of finer vessels is situated in
the muscular coat. Efferent vessels from the
cervical part drain into the deep cervical nodes.

10. ●
Vessels from the thoracic part drain to the
posterior mediastinal nodes and from the
abdominal part drain to the left gastric nodes.
Some vessels may pass directly to the thoracic
duct.Lymphatic drainage of the esophagus
contains little barrier to spread, and esophageal
lymphatics are densely interconnected. Hence,
esophagus carcinoma can spread through the
length of the esophagus via lymphatics and
may have nodal involvement several
centimeters away from the primary lesion.

12. NERVE SUPPLY
●
Upper 1/3rd
----Recurrent laryngeal branches of the
vagus nerve supply the striated muscle.
●
Motor supply to the nonstriated muscle is
parasympathetic, vagus.These fibers reach the
esophagus through the vagus and its recurrent
laryngeal branches. They synapse in the esophagus
wall in the ganglia of submucosal plexus (Meissner)
and myenteric plexus (Auerbach) between the outer
longitudinal and inner circular muscle fibers supply
mucous glands and smooth muscle fibers within the
walls

13. Vasomotor sympathetic fibers that supply the
esophagus arise from the upper 4-6 thoracic
spinal cord segments.The axons of these
neurons innervate the vessels of the cervical
and upper thoracic esophagus and distil
esophagus.

14. HISTOLOGY
●
Histologically, the esophagus has the following
4 concentric layers (see the image below)[3] :
●
Mucosal layer
●
Submucosal layer
●
Muscular layer
●
Adventitial layer

15. STOMACH
●
The stomach is the first intra-abdominal part of
the gastrointestinal (GI), or digestive, tract. The
stomach lies in the left upper quadrant of the
abdomen.The thoracic esophagus enters the
abdomen via the esophageal hiatus of the
diaphragm at the level of T10. The abdominal
portion of the esophagus has a small intra-
abdominal length (2-3 cm). The
esophagogastric junction (cardia), therefore,
lies in the abdomen below the diaphragm to the
left of the midline at the T11 level.

16. ●
The cardiac notch (incisura cardiaca gastri) is
the acute angle between the abdominal
esophagus and the fundus of the stomach,
which is the part of stomach above a
horizontal line drawn from the cardia. The
body (corpus) of the stomach leads to the
pyloric antrum (at the incisura angularis). The
pyloric antrum narrows toward the right to
become the pyloric canal, surrounded by the
pyloric sphincter, which joins the duodenum at
the L1 level (transpyloric plane) to the right of
the midline .

18. RELATIONS
●
The anterior surface of stomach is related to
the left lobe of the liver the anterior abdominal
wall, and the distal transverse colon. The
posterior surface of the stomach is related to
the left hemidiaphragm, the spleen, the left
kidney, and the pancreas (stomach bed).
●
The omental bursa (lesser sac) lies behind the
stomach and in front of the pancreas; it
communicates with the greater sac (main
peritoneal cavity) via the omental (epiploic)
foramen (of Winslow) behind the
hepatoduodenal ligament.

20. ●
The convex greater curvature of the stomach
starts at the left of the cardia and runs from
the fundus along the left border of the body of
the stomach and the inferior border of the
pylorus. The concave lesser curvature starts
at the right of the cardia as a continuation of
the right border of the abdominal esophagus
and runs a short distance along the right
border of the body of the stomach and the
superior border of the pylorus. The junction of
the vertical and horizontal parts of the lesser
curvature is called incisura angularis.

22. ●
The stomach and the first part of the
duodenum are attached to the liver by the
hepatogastric ligament (the left portion of the
lesser omentum), to the left hemidiaphragm by
the gastrophrenic ligament, to the spleen by
the gastrosplenic/gastrolienal ligament
containing short gastric vessels, and to the
transverse colon by the gastrocolic ligament
(part of the greater omentum). Few peritoneal
bands may be present between the posterior
surface of the stomach and the anterior
surface of the pancreas.

23. ●
Part of the greater omentum hangs like an
apron from the transverse colon, with 4 layers
of the peritoneum (often fused): 2 layers go
downward from the stomach and then run
upward to be attached to the transverse colon.

24. BLOOD SUPPLY
●
The celiac trunk (axis) arises from the anterior
surface of the abdominal aorta at the level of L1.
It has a short length (about 1 cm) and trifurcates
into the common hepatic artery (CHA), the
splenic artery, and the left gastric artery (LGA).
●
The LGA runs toward the lesser curvature of the
stomach and divides into an ascending branch
(supplying the abdominal esophagus) and a
descending branch (supplying the stomach).

26. ●
The CHA runs toward the right on the superior
border of the pancreas and gives off the
gastroduodenal artery (GDA), which runs
down behind the first part of the duodenum.
After giving off the GDA, the CHA continues as
the proper hepatic artery.The right gastric
artery, a branch from the proper hepatic artery,
runs along the lesser curvature from right to
left and joins the descending branch of the
LGA to form an arcade along the lesser
curvature supplying body of stomach.

27. ●
The GDA divides into the right gastro-omental
(gastroepiploic) artery (RGEA) and the anterior
superior pancreaticoduodenal artery (SPDA); it
also gives off the small supraduodenal artery
(of Wilkie). The RGEA runs along the greater
curvature from right to left.The splenic artery
runs toward the left on the superior border of
the distal body and tail of pancreas and gives
off the left gastro-omental artery (LGEA),

28. ●
which runs from left to right along the greater
curvature and joins the RGEA to form an arcade
along the greater curvature between the two
leaves of peritoneum of the greater omentum.

29. ●
The greater curvature arcade formed by the
RGEA and the LGEA provides several
omental (epiploic) branches to supply the
highly vascular greater omentum. The splenic
artery also gives off 3-5 short gastric arteries
that run in the gastrosplenic ligament and
supply the upper part of the greater curvature
and the gastric fundus. The stomach has a
rich network of vessels in its submucosa.

30. VENOUS DRAINAGE
●
The left gastric (coronary) vein drains into the
portal vein at its formation (by the union of the
splenic and superior mesenteric veins). The
right gastric and right gastro-omental veins
drain into the portal vein. The left gastro-
omental vein drains into the splenic vein, as
do the short gastric veins.

32. ●
The gastrocolic trunk is present in a large
number of cases and lies at the junction of the
small bowel mesentery and the transverse
mesocolon. It may drain the right colic, middle
colic, and right gastro-omental veins.
●
The short gastric arteries and veins are
sometimes collectively referred to as the vasa
brevia.

33. LYMPHATIC DRAINAGE

34. NERVE SUPPLY
●
The esophageal plexus of vagus (para-
sympathetic) nerves lies in the posterior
mediastinum below the hila of the lungs. It
divides into 2 vagal trunks that enter the
abdomen along with the esophagus through
the esophageal hiatus in the left dome of
diaphragm. The right (posterior) vagus is
behind and to the right of the intra-abdominal
esophagus, whereas the left vagus is in front
of the intra-abdominal esophagus.

35. ●
The right vagus gives off a posterior gastric
branch called the criminal nerve of Grassi,
which traverses to the left and supplies the
cardia and fundus of the stomach; the nerve is
so called because it is often missed during
vagotomy and is then responsible for
recurrence of peptic ulcer. The right vagus
gives off a celiac branch (which supplies the
pancreas and the small and large bowel), and
the left vagus gives off a hepatic branch (which
supplies the liver and the gallbladder).

36. ●
After giving off the celiac and hepatic
branches, respectively, the right and left vagal
trunks continue along the lesser curvature of
the stomach (in close company with the
vascular arcade formed by the left and right
gastric vessels) as the posterior and anterior
gastric nerves of Latarjet, which supply the
corpus (body) of the stomach, the antrum, and
the pylorus.

37. HISTOLOGY
●
The innermost lining of the
stomach wall is mucosa, which
consists of columnar epithelium,
lamina propria, and muscularis
mucosa. Submucosa contains a
rich network of blood vessels and
Meissner’s nerve plexus. The
smooth muscles of the stomach
are arranged in 3 layers: inner
oblique (unique to stomach),
middle circular (forms the
pylorus), and outer longitudinal.
These muscles are supplied by
the Auerbach’s nerve plexus.
Serosa is the visceral peritoneum
that covers most of the stomach.
Mucosa and submucosa are
thrown into several longitudinal
folds called rugae.

38. ●
The lower esophageal sphincter (LES), or
gastroesophageal sphincter, is not a true
(anatomic) sphincter; however, the pylorus is a
true sphincter composed of circular muscles.

39. ●
The lower esophageal sphincter (LES), or
gastroesophageal sphincter, is not a true
(anatomic) sphincter; however, the pylorus is a
true sphincter composed of circular muscles.

40. BENIGN TUMORS ESOPHAGUS
●
Benign tumours of the oesophagus account for
less than 1% of all oesophageal neoplasms.
Leiomyomas are the most common; rarer
entities include papillomas, fibrovascular
polyps, granular cell tumours, adenomas,
haemangiomas, neurofibromas, and lipomas.
●
Leiomyomas are smooth-muscle tumours
arising in the oesophageal wall. They are
usually solitary, well encapsulated with an intact
overlying mucosa, and grow slowly. Most small
(>5 cm) leiomyomas are asymptomatic and are
incidental finding on barium study .

41. MALIGNANT TUMOR OESOPHAGUS
●
Cancer in the upper two-thirds is a squamous
cell carcinoma and one in the lower one-third
is an adenocarcinoma.
●
RARE
leiomyosarcoma, malignant melanoma,
rhabdomyosarcoma, lymphoma ,muco-
epidermoid carcinoma, small cell carcinoma,
adenoid cystic carcinoma, adenosquamous
carcinoma.

42. FACTORS ASSOCIATED WITH
CARCINOMA ESOPHAGUS
●
Smoking , History of aerodigestive tract
malignancy*
●
Alcohol consumption, Achalasia*
●
Hot beverages*
●
N-nitroso compounds* Plummer vinson
(paterson kelley) syndrome*
●
Betel nut chewing*
●
Deficiencies of*:
●
Green vegetables Barrett's oesophagus†
●
Vitamins A, C and E

43. ●
in the past three decades was the increase in
incidence of adenocarcinomas of the lower
oesophagus and gastric cardia. Gastro-
oesophageal reflux disease, obesity, and the
pre-malignant condition of Barrett's
oesophagus.Barrett's oesophagus is a
condition in which the squamous epithelium of
the distal oesophagus is replaced by a
columnar epithelium characterized by the
presence of specialized intestinal metaplasia..
The Barrett's epithelium progresses through
low-grade to high-grade dysplasia to invasive

44. CLINICAL FEATURES
●
50 years of age
●
male predominance.
●
Dysphagia is the most common symptom, and is
rapid in onset, progressing from difficulty in swallowing
solid food and later to liquid within a matter of weeks.
Symptom of dysphagia is usually not felt until the
tumour is advanced.
●
Regurgitation (GERD)
●
, loss of weight,Haemorrhage
Cervical lymph nodes

45. Substernal pain or discomfort
●
Hoarseness signifies recurrent laryngeal nerve
palsy from direct tumour infiltration or from
lymphatic spread and is thus a poor prognostic
sign.
●
Coughing or choking on eating may be due to
aspiration, predisposed by the presence of
vocal cord palsy if present, or the development
of an oesophageal-respiratory fistula.
●
Squamous cell cancers of the oesophagus
rarely bleed.

46. ●
Fistulas may develop between the esophagus
and the trachea, increasing the pneumonia
risk;cough, fever or aspiration.
Hematogenous Spread:liver metastasis could
cause jaundice and ascites, lung metastasis
could cause shortness of breath, pleural
effusions.

47. INVESTIGATIONS
●
GENERAL: CBC
●
LFT
●
RFT
●
BLOOD GLUCOSE
●
VIRAL MARKERS
●
CHEST X RAY

48. INVESTIGATIONS
●
SPECIFIC:
UPPER GI ENDOSCOPY AND BIOPSY
●
A barium swallow identifies the location and
length of oesophageal narrowing, mucosal
irregularity, dilatation of the proximal
oesophagus.
●
CT SCAN
●
LAPAROSCOPY,LARYNGOSCOPY,
THORACOSCOPY,BRONCHOSCOPY

50. Stage groupings for oesophageal cancer
●
T: Primary tumour
●
Tx Tumour cannot be assessed
●
Tis In situ carcinoma
●
T1 Tumour invading lamina propria or the
submucosa, does not breach submucosa
●
T2 Tumour invading into but not beyond the
muscularis propria
●
T3 Tumour invades the adventitia but not the
adjacent structure
●
T4 Tumour invades the adjacent structure

51. ●
N: Regional lymph nodes*
●
NX Regional nodal status cannot be assessed
●
N0 No regional lymph node involvement
●
N1 Regional lymph node involved
●
M: Distant metastases
●
Mx Distant metastases cannot be assessed
●
M0 No distant metastasis
●
M1a Upper thoracic oesophagus with
metastases to cervical nodes.

52. ●
Lower thoracic oesophagus with metastases to
coeliac nodes
●
M1b Upper thoracic oesophagus with
metastases to other non-regional nodes or
other distant sites
●
Lower thoracic oesophagus with metastases to
other non-regional nodes or other distant sites
●
Middle thoracic oesophagus with metastases to
cervical, coeliac, other non-regional nodes or
other distant sites.

53. ●
For cervical oesophageal cancer, regional
nodes are the cervical nodes. For intrathoracic
cancers, the mediastinal and perigastric nodes
(excluding coeliac nodes), are considered
regional.

54. TNM STAGING
●
Stage 0 Tis N0 M0
●
Stage I T1 N0 M0
●
Stage IIa T2 N0 M0
●
T3 N0 M0
●
Stage IIb T1 N1 M0
●
T2 N1 M0
●
Stage III T3 N1 M0
●
T4 N0;N1 M0
●
Stage IVa Any T Any N M1a
●
Stage IVb Any T Any N M1b

55. ●
Endoscopic ultrasonography (EUS) is best in
T-stage and regional nodal (N) staging.Recent
advances also allow EUS-guided fine needle
aspiration cytology of suspicious lymph nodes
to be carried out.

56. PRINCIPLES OF TREATMENT
●
Patients with early disease generally do well
with surgical resection, provided an R0
resection (curative procedure with macroscopic
and microscopic clear margins) can be
performed.Patients with local-regional
advanced disease, upfront combined
treatments including chemotherapy and
radiotherapy are often used, and subsequent
surgical resection depending on response.
There is, however, no clear evidence that this
gives superior result to surgical resection alone.

57. OPERATIVE TREATMENT
●
Potential surgical candidates should have a
careful risk assessment especially with
regards to cardiopulmonary status. Smoking
should be stopped and active chest
physiotherapy instituted.
●
Pre-operative enteral nutrition or parenteral
nutrition may be beneficial.

58. OPERATIVE TREATMENT
●
Potential surgical candidates should have a
careful risk assessment especially with
regards to cardiopulmonary status. Smoking
should be stopped and active chest
physiotherapy instituted.
●
Pre-operative enteral nutrition or parenteral
nutrition may be beneficial.

59. ENDOSCOPIC MUCOSAL RESECTION
●
Forms of endoscopic therapy have been used
for Stage 0 and I disease: endoscopic
mucosal resection (EMR) and mucosal
ablation using radiofrequency ablation,
photodynamic therapy, Nd-YAG laser, or argon
plasma coagulation.
●
The major complications of endoscopic
mucosal resection include postoperative
bleeding, perforation and stricture formation.

60. ●
If the person cannot swallow at all, an
esophageal stent may be inserted to keep the
esophagus open; stents may also assist in
occluding fistulas. A nasogastric tube may be
necessary to continue feeding while treatment
for the tumor is given, and some patients
require a gastrostomy /iliostomy(feeding hole
in the skin that gives direct access to the
stomach). The latter two are especially
important if the patient tends to aspirate food
or saliva into the airways, predisposing for
aspiration pneumonia.

61. Oesophagectomy
is the removal of a segment of the esophagus; as this shortens the
length of the remaining esophagus, some other segment of the
digestive tract (typically the stomach or part of the colon or jejunum)
is pulled up to the chest cavity and interposed.[29] If the tumor is
unresectable or the patient is not fit for surgery, palliative esophageal
stenting can allow the patient to tolerate soft diet.
Types of esophagectomy:
The thoracoabdominal approach opens the abdominal and thoracic
cavities together.
The two-stage Ivor Lewis (also called Lewis–Tanner) approach
involves an initial laparotomy and construction of a gastric tube,
followed by a right thoracotomy to excise the tumor and create an
esophagogastric anastomosis.
The three-stage McKeown approach adds a third incision in the neck
to complete the cervical anastomosis.

62. ●
Lewis-Tanner (Ivor Lewis) operation
●
For tumours of the middle and lower third of the
oesophagus.The stomach, the blood supply of
which is based on the right gastric and right
gastroepiploic vessels, is mobilised via
laparotomy. A pyloroplasty or pyloromyotomy is
performed to enhance gastric drainage. The
oesophagus is then resected through a right
thoracotomy. The stomach is delivered up into
the thorax via the diaphragmatic hiatus to
anastomose with the divided oesophagus near
the apex of the thoracic cavity.

64. ●
In type II and III tumours around the
gastrooesophageal junction, an extended total
gastrectomy with a distal oesophageal
resection is often performed, although some
surgeons advocate a proximal gastric and distal
oesophageal resection. Both can be
accomplished via the abdomen or with an
additional thoracotomy.
●
In tumours of the upper thoracic oesophagus,
oesophagectomy can be performed through a
right thoracotomy, then by simultaneous left
cervical and abdominal incisions the stomach
can be prepared and delivered up to the neck
for anastomosis

65. McKeown's procedure
●
A three-phase oesophagectomy. The colon is
placed in the retrosternal route in this example
with anastomosis in the neck.
●
In transhiatal oesophagectomy, the
oesophagus is ‘shelled’ out by the surgeon's
hand introduced in the posterior mediastinum
via the diaphragmatic hiatus and the neck
without a thoracotomy. This partly blind
procedure may lead to injury to mediastinal
structures, such as the membranous trachea,
and has also been criticised as an inadequate
cancer operation.

66. ●
In experienced hands however, it is safe, and
its proponents claim similar survival to the
transthoracic approach. Various minimal-
access methods including combinations of
thoracoscopy, laparoscopy and
mediastinostomy have been attempted.
●
lymphadenectomy of the upper abdomen and
mediastinum (two-field dissection).
●
the addition of bilateral neck dissection (three-
field dissection) because of the high incidence
of positive cervical lymph nodes found when
neck dissection is carried out (up to 30%), and
better cure rate.

67. ●
The stomach is most commonly used for
oesophageal substitution. In patients with
previous gastric surgery, other substitutes like
the colon or jejunum can be used. In cases
where the substitute is brought to the neck for
anastomosis, the posterior mediastinum
(orthotopic), retrosternal route or subcutaneous
space are alternatives.
●
Tumours of the cervical oesophagus require the
resection of the larynx and pharynx, and the
stomach is usually used to restore continuity
(pharyngo-laryngo-oesophagectomy).

68. ●
A terminal tracheostome is performed and
alternative voice rehabilitation is required. For
tumours limited to the postcricoid region,
resection need not involve the thoracic
oesophagus and a free jejunal graft can be
placed in the neck to restore intestinal
continuity after pharyngo-laryngectomy. For
these tumours, in order to preserve the larynx,
often non-operative treatment such as
chemoradiation therapy is used as an
alternative to surgical resection.

69. COMPLICATIONS
●
Cardiac
●
Atrial arrhythmia*
●
Myocardial infarction
●
Cardiac failure
●
Pulmonary
●
Atelectesis*
●
Pneumothorax
●
Bronchopneumonia with or without aspiration*
●
Sputum retention*

70. ●
Pleural effusion*
●
Pulmonary embolism
●
Other medical†
●
Renal failure
●
Hepatic failure
●
Stroke

71. ●
Surgical
●
Intra-operative or post-operative haemorrhage
●
Tracheo-bronchial tree injury
●
Recurrent laryngeal nerve injury
●
Anastomotic leakage
●
Gangrene of conduit,,Intra-thoracic gastric
outlet obstruction or gastric stasis
●
Herniation of bowel through diaphragmatic
hiatus
●
Chylothorax ,Empyema,Wound infection

72. CHEMORADIO THERAPY
NON OPERATIVE TREATMENT
●
Chemoradiation therapy gives superior result
to radiation alone in the treatment of
oesophageal cancer, both in terms of response
rate, local control, and long-term survival.
Radiotherapy alone has thus mostly a palliative
role in patients who cannot tolerate the addition
of chemotherapy. Brachytherapy, or intraluminal
radiotherapy, whereby radioactivity is delivered
in close proximity to the tumour via a tube
placed inside the oesophagus, can also
produce good palliation.

73. ●
neo-adjuvant or adjuvant therapy with surgery.
●
cisplatin and flurouracil.
●
Placement of a prosthetic tube across the
tumour stenosis may be indicated in patients
not otherwise suitable for other treatment to
palliate the symptom of dysphagia. Traditional
tubes placed by laparotomy (e.g. Celestin tube,
Mousseau-Barbin tube) or oesophagoscopy
under sedation (e.g. Atkinson tube, Souttar
tube) are now rarely used since they have been
superseded by a variety of self-expanding
metallic stents.

74. ●
Laser therapy (Neodymium:yttrium aluminium
garnet [Nd:YAG] laser) vaporises the tumour to
restore luminal patency. Recannulation often
requires repeated treatment sessions, and the
effect is temporary.
●
Other less commonlY ,injection of the tumour
with alcohol or chemotherapeutic agents,
photodynamic therapy, and use of a bicap
heater probe. The choice of therapy depends
on availability, cost and consideration of
efficacy.

75. PROGNOSIS
Patients with squamous cell carcinomas and
who undergo surgical resection alone, 5-year
survival of patients with stage I 83% ,
●
II 32%
●
III 13%
●
IV 7%

77. ADENOCARCINOMA STOMACH
●
2ND COMMONEST AND 90% OF STOMACH
MALIGNANCIES.
●
Gastric cancer overall has a poor prognosis in
most countries with overall 5 years' survival
rate being around 10%.
●
Gastric cancer is generally a disease of the
elderly, with average age at presentation being
70 years and a 2 to 1 male to female
predominance

78. ●
The commonest site of cancers was in the
antrum of the stomach.Over the past 5
decades, antral gastric cancer has become
less common whereas proximal third cancers
more common - to a point where proximal
cancers are now the most commonly seen in
most developed countries.The key identified
aetiological factors for non-cardia gastric
cancer are Helicobacter pylori infection(60%),
high nitrite intake, low intake of fruit and
vegetables, smoking and high salt intake.

79. TYPES ACCORDING TO
PATHOGENESIS
●
Two broad histological types of gastric cancer,
Intestinal type cancers
●
Diffuse type cancers (HEREDITARY--GENE)
●
(around 20–30% have a mixed picture)

80. CLINICAL FEATURES
Indigestion or a burning sensation (heartburn).
Less than 1 in every 50 people going to a
doctor with indigestion have cancer.
●
Loss of appetite, especially for meat
●
Abdominal discomfort or irritation
Weakness and fatigue
●
Bloating of the stomach, usually after meals

81. CLINICAL FEATURES
Abdominal pain in the upper abdomen
●
Nausea and occasional vomiting
●
Diarrhea or constipation
●
Weight loss
●
Bleeding: vomiting blood or having blood in
the stool, the latter apparent as black
discoloration (melena) and sometimes leading
to anemia.
●
Dysphagia: if extension of the gastric tumor
into the esophagus.

83. INVESTIGATIONS
●
CBS (ANEMIA),LFT,
●
esophagogastroduodenoscopy or EGD
●
Double-contrast upper GI series and barium
swallows may be helpful in delineating the
extent of disease when obstructive symptoms
are present or when bulky proximal tumors
prevent passage of the endoscope to examine
the stomach distal to an obstruction (more
common with gastroesophageal [GE]-junction
tumors). These studies are only 75% accurate
and should for the most part be used only
when upper GI endoscopy is not feasible.

85. ●
CT scan or MRI of the chest, abdomen, and
pelvis assess the local disease process as
well as evaluate potential areas of spread (ie,
enlarged lymph nodes, possible liver
metastases).
●
Endoscopic ultrasound allows for a more
precise preoperative assessment of the tumor
stage. Endoscopic sonography is becoming
increasingly useful as a staging tool when the
CT scan fails to find evidence of T3, T4, or
metastatic disease.

87. STAGING
●
Stage 0 - Tis, N0, M0
●
Stage IA - T1, N0 or N1, M0
●
Stage IB - T1, N2, M0 or T2a/b, N0, M0
●
Stage II - T1, N2, M0 or T2a/b, N1, M0 or T2,
N0, M0
●
Stage IIIA - T2a/b, N2, M0 or T3, N1, M0 or
T4, N0, M0
●
Stage IIIB - T3, N2, M0
●
Stage IV - T1-3, N3, M0 or T4, N1-3, M0, or
any T, any N, M1

88. SURVIVAL RATES
●
Stage 0 - Greater than 90%
●
Stage Ia - 60-80%
●
Stage Ib - 50-60%
●
Stage II - 30-40%
●
Stage IIIa - 20%
●
Stage IIIb - 10%
●
Stage IV - Less than 5%.

89. TREATMENT OPTIONS
●
DEPENDS ON STAGE
●
SURGICAL ----CURATIVE
●
-----PALLIATIVE
NON SURGICAL
CHEMO RADIOTHERAPY

90. SURGERICAL RESECTIONS
●
Endoscopic mucosal resection:
Resection mucosa in Early stage Disease
●
Partial(stapler anastomosis ) ,Total
Gastrectomy , Laparoscopic Gastrectomy

91. PARTIAL GASTRECTOMY
●
INDICATIONS
●
Gastric neoplasia
●
Recurrent ulcerations after truncal vagotomy and antrectomy
●
CONTRAINDICATIONS
●
Ascites (relative)
●
Unless indicated for palliation, gastrectomy is not performed in
the presence of:
●
Peritoneal disease
●
Hepatic metastases
●
Diffuse nodal metastases

92. PARTIAL GASTRECTOMY
●
INCISION:
An upper midline incision from the xiphoid
process to the umbilicus with an optional
extension inferior to the umbilicus provides
quick and bloodless access to the abdomen.
●
A thorough exploration of the abdominal cavity
to look for metastasis in the liver, peritoneum,
omentum, and pelvis is performed first.

93. ●
After resection of the stomach, continuity can
be achieved via gastroduodenal anastomosis
(Billroth I). A tension-free gastroduodenal
anastomosis requires good duodenal
mobilization. The second option is to close the
duodenal end and to perform a gastrojejunal
anastomosis (Billroth II or its modifications).
Two main variations to the gastrojejunal
anastomosis include an end-to-side
gastrojejunostomy using an uninterrupted loop
of jejunum and an end-to-side
gastrojejunostomy to a Roux loop.

94. Duodenal mobilization:
●
perform a gastroduodenal anastomosis
●
The duodenum is mobilized by incising the
peritoneum along its lateral border and then
reflecting the duodenum to the left side until
the inferior vena cava is exposed. This
process is also referred to as Kocherization.
●
avoid injury to the structures in the lesser
omentum and middle colic vessels

95. ●
Omental mobilization:
●
The greater omentum is freed from the
transverse colon by dividing along the
avascular plane between the transverse colon
and the anterior leaf of the omentum.
●
injury to the middle colic artery.The posterior
wall of the stomach is freed by dividing
gastropancreatic folds of peritoneum.

96. Duodenal division
●
The right gastric artery is identified at the
inferior end of the lesser curvature.This is
doubly ligated and divided. Similarly, the
gastroepiploic artery is identified close to the
inferior end of the greater curvature, doubly
ligated, and divided.At this point, about 1-2 cm
of duodenum adjacent to the pylorus is
cleared of all fat and vascular adhesions. Care
is taken to avoid injury to the pancreatic tissue
while clearing the duodenum. The duodenum
is divided by a linear cutter.

97. ●
Gastric division
Greater curvature of the stomach is mobilized
further by dividing the gastrosplenic ligament.
Depending on the extent of gastrectomy
planned, the greater curvature is mobilized to
the point where the gastroepiploic artery is
closest to the gastric wall (hemigastrectomy)
or farther proximally to the second short
gastric artery (subtotal gastrectomy). The first
short gastric artery is left behind to supply the
remnant stomach.

98. The left gastric artery is divided as
a part of subtotal gastrectomy.
This artery divides into two
branches close to the lesser
curvature. The left gastric artery is
secured via double ligation or
ligation followed by transfixing
suture on the arterial side and a
tie on the gastric side before
being divided.Stomach is divided
with a linear cutter at the site
identified for proximal resection.
At this stage, the specimen is
delivered out.

99. Lymph Node Dissection
Lymph node dissection can be categorized into D1, D2, D3,
or D4 based on the lymph node stations,
●
D1 lymphadenectomy: Removal of perigastric nodes (3
cm around tumor)
●
D2 lymphadenectomy: Removal of nodes along the left
gastric artery, common hepatic artery, celiac trunk,
splenic hilus, and splenic artery
●
D3 lymphadenectomy: Include dissection of lymph nodes
along the hepatoduodenal ligament, posterior surface of
the head of the pancreas, and the root of the mesentery
(superior mesenteric vessels)
●
D4 lymphadenectomy: Dissection along the para-aortic
and paracolic region

100. ●
Resection of adjacent organs
●
Resection of adjacent organs (eg, distal
pancreas, spleen, colon) is performed for
lesions with direct involvement into these
structures. Distal pancreatectomy and
splenectomy are not performed as part of a
conventional D2 lymphadenectomy owing to
increased postoperative morbidity and
mortality.

101. Reconstruction
Reconstruction is performed with Billroth I or Billroth II.
Billroth I
A part of the staple line on the gastric side in the inferior
aspect toward the greater curvature is opened up
corresponding to the duodenal end diameter.
Interrupted delayed absorbable sutures are taken from
the middle of the posterior walls of the stomach and the
duodenum. After all sutures are placed along the
posterior layer, they are tied starting from the lesser
curvature side. Once secured, the anterior layer is then
similarly sutured.

102. ●
Billroth II
●
The duodenal stump remains closed. A loop of jejunum is
identified close to the duodenojejunal flexure.The loop is
anchored to the posterior wall of the stomach with
delayed absorbable seromuscular sutures. An opening is
made in the jejunum equal to about twice the diameter of
Anastomosis is performed with a continuous suture of
absorbable suture starting from the middle of the
posterior layer on either side and continued to meet in
the middle of the anterior layer. A fourth layer of
seromuscular sutures is placed to bury the anterior
continuous suture line. The staple line on the stomach is
opened to correspond to this length.

103. ●
The abdominal wound is lavaged thoroughly. A
right subhepatic drain is useful in early
detection of a possible duodenal stump
blowout. The abdominal wound is then closed
in layers.

104. TOTAL GASTRECTOMY
●
INDICATIONS
●
Linitis plastica
●
Carcinoma of the proximal (upper third)
stomach
●
Lymphosarcoma
●
Sarcomatous degeneration of multiple
leiomyomas
●
Complicated lymphoma of the stomach that
cannot be treated with chemotherapy plus
radiotherapy
●
Palliation

105. ●
CONTRAINDICATIONS
●
Ascites (relative)
●
Unless it is the only palliative option in the
presence of
●
Peritoneal disease
●
Hepatic metastases
●
Diffuse nodal metastases

106. PROCEDURE
●
Stomach removed ,tissue
surrounding,Regional lymph nodes are often
removed during surgery (called a
lymphadenectomy) because the cancer may
have spread to those lymph nodes.
●
Roux-en-Y anastomosis: Roux-en-Y, is a
surgically created (end-to-side) anastomosis.
Typically, it is between stomach and small
bowel that is distal (or further down the
gastrointestinal tract) from the cut end.[1]

107. COMPLICATIONS
●
INFECTION
-PERITONITIS,ABSCESS,SEPSIS
●
VENOUS THROMBOEMBOLISM
●
HERNIA
●
HEMMORHAGE
●
ADHESION OBSTRUCTION
●
ANASTOMOSIS LEAK,STRICTURE,ULCER
●
NUTRITIONAL DEFICIENCIES

108. DUMPING SYNDROME
●
Normally, the pyloric valve at the lower end of the
stomach regulates the release of food into the bowel.
When the gastric bypass patient eats a sugary food,
the sugar passes rapidly into the intestine, where it
gives rise to a physiological reaction called dumping
syndrome. The body will flood the intestines in an
attempt to dilute the sugars. An affected person may
feel their heart beating rapidly and forcefully, break
into a cold sweat, get a feeling of butterflies in the
stomach, and may have an anxiety attack. The
person usually has to lie down, and could be very
uncomfortable for 30–45 minutes. Diarrhea may then
follow.

109. CHEMOTHERAPY
●
Palliatively reduce the size of the tumor, relieve symptoms of the
disease and increase survival time. Some drugs used in stomach
cancer treatment have included: 5-FU (fluorouracil) or its analog
capecitabine, BCNU (carmustine), methyl-CCNU (semustine) and
doxorubicin (Adriamycin), as well as mitomycin C, and more
recently cisplatin and taxotere, often using drugs in various
combinations. The relative benefits of these different drugs, alone
and in combination, are unclear.[47] Clinical researchers have
explored the benefits of giving chemotherapy before surgery to
shrink the tumor, or as adjuvant therapy after surgery to destroy
remaining cancer cells.[2] Recently, a targeted treatment called
trastuzumab available.
Radiation therapy (also called radiotherapy) may also be used to treat
stomach cancer, often as an adjuvant to chemotherapy and/or
surgery.

110. PROGNOSIS
●
The prognosis of stomach cancer is generally poor,
due to the fact the tumour has often metastasised by
the time of discovery and the fact that most people
with the condition are elderly (median age is between
70 and 75 years) at presentation. The 5-year survival
rate for stomach cancer is reported to be less than
10%.