Dr. Pankaj TejasviDept. of SurgeryMGMMC & MYH Indore

MANAGEMENT OF GASTRIC CANCER

ANATOMYGE Junction –

Z – line / Squamocolumnar jn.

Rugal folds Fat pad Collar of Helvetius /

Loop of Willis

DIVISIONS OF STOMACH –

Cardia Fundus Body / Corpus Pyloric antrum Pyloric canal

PYLORUS

*Prepyloric vein of Mayo

INNERVATIONPARASYMPATHETIC* Vagus - left/anterior - hepatic branch - anterior n. of Latarjet right/posterior - criminal n. of Grassi - celiac branchSYMPATHETIC* Greater splanchinic nerve (T5-9)

ENTERIC NERVOUS SYSTEM* Meissner’s plexus (submucosal)* Auerbach’s myenteric plexus

Rt. vagus

Celiac br.

VASCULAR SUPPLYCELIAC TRUNK

*Lt gastric artery*Rt gastric artery

*Lt gastroepiploic artery*Rt gastroepiploic artery

*Short gastric arteries

* Inferior phrenic arteries

LYMPHATICS 4 zones

Celiac group

Thoracic duct

Paracardial

LGE nodes

RGE nodes

Left gastric nodes

LAYERS OF STOMACH

Subserosal CT

EPIDEMIOLOGY of Gastric Cancer

East Asia and South AmericaMost common cancer in JAPAN

M : F = 2 : 17th decade

JAPAN

THE MAGNITUDE OF PROBLEMMale : Lung > Prostate > Colorectal > Stomach

4th most common cancer in men

Female : Breast > Cervix > Colorectal > Lung > Stomach

5th most common cancer in women

*2nd most commom cause of cancer death*Poor prognosis*India : Kashmir - 36/1,00,000

Chennai - 15/1,00,000Bangalore - 10.6/1,00,000

Around 45-50% of gastric carcinoma present with an inoperable disease.

*RISK FACTORSNutritional*Salted/smoked meat or fish (nitrate N-nitroso compounds)

*Low fresh fruits and vegetable (ascorbic acid)

*High complex carbohydrate consumption

*Low fat or protein consumption

Environmental* Poor food preparation (smoked, salted)* Lack of refrigeration* Poor drinking water (e.g., contaminated well water)* Smoking

Medical* Prior gastric surgery (bile gastritis)

* H. pylori infection (not a/w tumors of cardia)

* Gastric atrophy and gastritis

Hereditary* Hereditary diffuse gastric cancer (E-catherin – CDH1 gene)

80% lifetime incidence

prophylactic total gastrectomy

* Familial Adenomatous polyposis (APCgene, MUTYH gene) 10%-20% risk ∞ size

Pedunculated- Endoscopic removal Sessile and >2cm- excise

* Duodenal Polyps

* Li – Fraumeni syndrome / SBLA syndrome (p53)

* Lynch syndrome / HNPCC -hereditary nonpolyposis colorectal cancer (MLH1 or MSH2 mutation)

Others* Male gender

* Pernicious anaemia (achlorhydria)

* Proto oncogene overexpression – c-met , k-sam , c-erbB2

* Inactivation of tumor suppressor gene – p53 and p16

H.Pylori & Gastric carcinoma• RESERVOIRS: human, primates, cats,

sheeps.• Gram-negative spiral bacillus.• Grows at pH: 4.5-9• M/C site of colonisation - antrum

Virulence : cagA gene

Mutation : p53Over-expression : COX-2, cyclin D2Decrease expression : p27Microsatellite instability

PPI and Gastric cancer

Impact of PPI on incidence of

gastric cancer has not been elucidated.

....Sabiston textbook of surgery 19th

ed.

• PPI blocks H+-K+ pump• Hypergastrinemia• Hyperplasia of G-cells & ECL

cells• Carcinoid tumors in rats

In patients with H.pylori on long term PPI, the low acid environment allows bacteria to colonize the gastric body, leading to corpus gastritis.1/3rd develop atrophic gastritis.(a risk factor for carcinoma)

HISTOLOGICAL TYPES OF GASTRIC CANCER

*Adenocarcinoma – 90%*Lymphoma – 5%*GIST – Gastrointestinal stromal tumors – 2%*SCC – Squamous cell carcinoma - <1%*Carcinoid tumors - <1%*Adenocanthoma - <1%*Signet ring cell Carcinoma

Signet ring cell carcinoma (SRCC)

• Rare form of highly malignant adenocarcinoma• Cells contain abundant mucin in the cytoplasm. So nucleus is shifted to periphery to

produce “signet ring” shape.• Location – M/c in stomach; and less frequently in breast, gallbladder, urinary bladder,

and pancreas

• Contrary to others gastric cancer, the incidence of SRCC of the stomach is rising.

• SRCC tumors grow in characteristic sheets, which makes diagnosis using standard imaging techniques, like CT and PET scans, less effective.

• Causes: - inherited - mutations in CDH1 gene (cell-cell adhesion glycoprotein E-cadherin) Once these cells lose E-cadherin, their motility increases- APC gene mutation

• PrognosisEarly SRCC – better or atleast similar to than of non-SRCCAdvanced SRCC – poor than non-SRCC and lower chemosensitivity and peritoneal carcinomatosis is the most frequent metastatic site.

A ring that kills….

PATHOLOGIC CLASSIFICATION

1) Borrmann classification system (1926)2) Lauren Classification System (1965)3) WHO System (1990)

• Based on macroscopic apperance• Useful as endoscopic finding

BORRMANN CLASSIFICATION

Protruded type

Depressed type

Type 1

Type 2

Type 3

Type 4

Type 5

Phymatoid/polypoid

Ulcerative

Infiltrative ulcerative

Diffuse infiltrative

Can’t be classified

INTESTINAL type DIFFUSE typeEnvironmental FamilialGastric atrophy, Intestinal metaplasia

Blood type A

M > F F > MIncreasing incidence with age Younger age group

Gland formation Poorly differentiatedHematogenous spread Transmural, lymphatic spread

Microsatellite instabilityAPC gene mutation

Decreased E-cadherin (CDH1 gene)

Inactivation of tumor suppressor genes p53, p16Exophytic, bulky lesion Ulcerating lesion

Frequent intraperitoneal metastasis.LINITIS PLASTICA

LAUREN CLASSIFICATION

WHO Classification of Gastric Cancer

Classification based on morphologic features

Adenocarcinoma – divided according to the growth pattern in :

- papillary- tubular- mucinous- signet ring

Adenosquamous cell carcinoma Squamous cell carcinoma Undifferentiated Unclassified

*Clinical features Asymtomatic – 70%

Symptoms are nonspecific

advanced diseaseat the time of diagnosis

*Epigastric pain*Nausea and vomitting*Early satiety*Weight loss

*GI bleeding - Anemia 40% - frank hematemesis 15% - Melaena

*Palpable mass – Linitis Plastica

*Virchow’s nodes / Troisier’s sign

*Sister Mary Joseph’s node

*Hepatomegaly, jaundice, ascites

*Krukenberg’s tumor

*Blummer’s shelf

*2011 consensus guidelines

advocate that patients ≥ 55yr with new onset dyspepsia and

all those with alarm features

should have an urgent (within two weeks) gastroscopy

“Alarm” features suggestive of gastric cancer

*New onset dyspepsia in patients >55 years of age*Family history of UGI cancer*Unintentional weight loss*Upper or lower GI bleeding*Progressive dysphagia*Iron deficiency anaemia*Persistent vomiting*Palpable mass*Palpable lymph nodes*Jaundice

STAGING OF GASTRIC CANCER

Physical examination

Blood tests

Imaging

Skin changesPalpable mass

CBC – anaemiaS.E. – GOOLFTEUSCECT

2 major staging systems for gastric carcinoma

American Joint Committee on Cancer classification Japanese Classification of Gastric Carcinoma

Japanese classification uses T and M staging similar to the AJCC system

Nodal staging is significantly different• AJCC focuses on number of positive LN• The Japanese classification focuses on anatomic location

of the nodes, which are designated by stations

AJCC TNM STAGING

T1a

T1b

Depth of tumor invasion

Number of involved LN

Presence or absence of metastatic disease

TX – Primary tumor can’t be assessed

T0 – No evidence of primary tumor

Tis- Carcinoma in situ

Mucosa

Submucosa

Muscularis propria

Subserosal CT

Serosa

T3 – gastro- colic/hepatic lig., greater or lesser omentum

RE GIONAL LYMPH NODES (N)Based on number of LN involved and not the location

In 1997, nodal classification changed from using the location of the involved lymph nodes to the number of lymph nodes

pN1, 1–6 nodespN2, 7–15 nodespN3, >15 nodes

-Requires a minimum of 15 nodes in the resection specimen-Avrg no. of nodes evaluated - 10, only 30% of pts have at least 15 nodes evaluated

NX - Regional lymph node(s) cannot be assessedN0 - No regional lymph node metastasis§N1 - Metastasis in 1-2 regional lymph nodesN2 - Metastasis in 3-6 regional lymph nodesN3 - Metastasis in 7 or more regional lymph nodes N3a - 7-15 nodes N3b - 16 or more nodes

M0 - No distant metastasisM1 - Distant metastasis

DISTANT METASTASIS (M)

Because of inadequate nodal evaluationIn the 7th edition of the AJCC classification, a minimum of

7 nodes are required.

TNM StageT1 T2 T3 T4a T4b

N0 IA IB IIA IIB IIIBN1 IB IIA IIB IIIA IIIBN2 IIA IIB IIIA IIIB IIICN3 IIB IIIA IIIB IIIC IIIC

Changes in the 7th edition of AJCC classification

GE junction tumorsor

tumors in the cardia <5cm from GE junction extending into GE junction

Staged using the TNM staging for esophageal cancerRüdiger et al. Ann Surg 2000; 232-353

*Nodal staging is significantly different

*Focuses on Anatomic location of the nodes, which are designated by stations

*recommendes nodal basin dissection dependent on the location of the primary

The Japanese Classification for GastricCarcinoma (JCGC) staging system

* No. 1 Right paracardial LN

* No. 2 Left paracardial LN

* No. 3 LN along the lesser curvature

* No. 4sa LN along the greater curvature – 4sa (short gastric vessels)

- 4sb (left gastroepiploic vessels)

- 4d (right gastroepiploic vessels)

* No. 5 Suprapyloric LN

* No. 6 Infrapyloric LN

* No. 7 LN along the left gastric artery

* No. 8 LN along the common hepatic artery - 8a(anterior group)

- 8p(posterior group)

* No. 9 LN along the celiac artery

* No. 10 LN at the splenic hilum

* No. 11 LN along the splenic artery – 11p proximal splenic

- 11d distal splenic

* No. 12 LN in the hepatoduodenal ligament – 12a (along the hepatic artery)

– 12b (along the bile duct)

– 12p (behind the portal vain)

* No. 13 LN on the posterior surface of the pancreatic head

* No. 14 LN along the superior mesenteric vessels – 14v superior mesenteric vein

- 14a superior mesenteric artery

* No. 15 LN along the middle colic vessels

* No. 16a1 LN in the aortic hiatus

* No. 16a2 LN around the abdominal aorta (from upper margin of celiac trunk to the lower margin of left renal vein)

* No. 16b1 LN around the abdominal aorta (from lower margin of left renal vein to the upper margin of inferior mesenteric artery)

* No. 16b2 LN around the abdominal aorta (from the upper margin of inferior mesenteric artery to aortic bifurcation)

Right paracardial

Left paracardial

lesser curvature

short gastric

left gastroepiploic

right gastroepiploic

Suprapyloric

Infrapyloric

left gastric artery

common hepaticCELIAC

Splenic hilum

Proximal & distal splenic

Hepatoduodenal ligament-Hepatic artery-Portal vein-Bile duct

Posterior of pancreatic head

superior mesenteric vein

superior mesenteric artery

15middle colic artery and vein

Mesentric root

Transverse mesocolon

16a1aortic hiatus

16a2

16b1

16b2

Celiac trunk

Lt. renal vein

Inferior mesentric artery

20Esophageal hiatus

No. 17 anterior surface of pancreas headNo. 18 inferior margin on the pancreasNo. 19 Infradiaphragmatic LN

Staging Evaluation

*Once the diagnosis is established, further studies are directed at staging to assist with therapeutic decisions

*EUS and CT are primary radiological staging modalities*Others – MRI, PET scan, laparoscopy

Endoscopy and Endoscopic Ultrasound(stomach is filled with water)(biopsy)

*T staging -The gastric wall is visualized as 5 concentric bands:Mucosa - EchogenicMuscularis mucosa - HypoechoicSubmucosa - EchogenicMuscularis propria - HypoechoicSerosa - Echogenic

*N staging - presence and location of peri-visceral lymph nodes or detection of malignant cells by EUS guided trans-visceral FNA

*Less useful for M staging, due to limited depth of penetration However, with low frequency newer echo-endoscopes, much of the liver can be surveyed and sampled from

the stomach and duodenum

In the future, EUS may play a role in determining those patients who require further aggressive investigation of metastatic disease (e.g., laparoscopy) and those who do not.

gastric tumor - hypoechoic mass

Computed Tomography

*useful for M staging- primary method for detection of intra-abdominal metastatic disease,

with an overall detection rate of approximately 85%.

For detecting SENSITIVITY SPECIFICITYLiver metastasis

75% 99%

Peritoneal metastasis

33% 95%

T staging and N staging –

The accuracy of T and N stages as determined by CT is less accurate than EUS. Sabiston textbook of surgery 19th ed.

* Accuracy for T staging - 64%Paramo JC et al. Ann Surg Oncol1999;6:379-84

* Sensitivity for N staging – 50 to 95%Irving, recent advances in surgery.

CT and MRI are not useful in distinguishing between enlarged nodes due to reactive changes and those due to tumor.

MRIWhen CT iodinated contrast is contraindicated

* For T staging, MR is comparable or minimally superior to CTSohn KM et al. AJR Am J Roentgenol 2000;174:1551-7

* Inferior to CT in N staging

* M staging - Improvement in detection of metastatic disease compared with CT, when the contrast Ferumoxtran-10 is used (sensitivity 100%)

Coburn NG. J Surg Oncol 2009;99(4):199–206

Motohara T, Semelka RC. Abdom Imaging 2002;27(4):376–83

PET scan

*not currently a primary staging modality.*Only 50% gastric cancers are PET-avid*PET response to neoadjuvant therapy seen after 14 days of

treatment strongly correlates with survival, therefore for monitoring response to these therapies, sparing unresponsive patients further toxic treatment

Staging LaparoscopyIn 1985, report by Shandall and Johnson

Detection of metastatic disease to the liver or peritoneum* Sensitivity - 100%, specificity - 84%

*Avoidance of laparotomies - 29% of pts

Now N staging is possible with laparoscopic ultrasound

Implications*In resectable pts. for staging *In unresectable pts. – determination of benefits of combined chemo-

radiation (radiation may not be appropriate in metastatic disease)Jaffer A et al. http://www.nccn.org, v.1.2006

*Staging before entry into neo-adjuvant trialsD’Ugo DM et al. J Am Coll Surg 2003;196:965-74

Not necessary in T1 or T2 lesions given the low incidence of metastases.

CT scanning and endoscopic ultrasonography (EUS) are complementary.

CT scanning is used first to stage the gastric carcinoma; if no metastases and no invasion of local organs are found, EUS is used to refine the local stage.

The depth of tumor invasion is not accurately assessed with CT, and the investigation of choice for this indication is EUS.

Unlike CT and MRI, EUS can depict individual layers of the gastric wall, with a rotating high-frequency probe

SURGICAL THERAPY – the only prospective of cure

Objective : Complete resection of gastric tumor with a wide (≥6cm) margin

what is R status ?

Describes tumor status after resection

• R0 – microscopically margin-negative resection.• R1 – macroscopic clearance of tumour but microscopic margins are positive.• R2 – gross residual disease.

…Hermanek, 1994

Total gastrectomy should not as a routine procedure for gastric adenocarcinoma.

Patients in whom R0 resection can be obtained, a more limited gastric resection (e.g., proximal esophagogastrectomy or distal subtotal gastrectomy) provides the same survival result less perioperative morbidity.

Surgery

Endoscopic sub-mucosal resection

Hemi- gastrectomy

Subtotal gastrectomy

Total gastrectomy

EMR and ESR

EMR (Endoscopic mucosal resection)

injection of a substance under the targeted lesion to act as a cushion,lesion is then removed with a snare or suctioned into a cap and snared

.

ESR (Endoscopic sub-mucosal resection)

injection of a substance under the targeted lesion to act as a cushion,submucosa is instead dissected under the lesion with a specialized knife.This enables removal of larger and potentially deeper lesions

higher rates of R0 resections and a lower rate of local recurrence, but technically demanding and has more adverse events.

DisadvantageIncomplete resection d/t large tumor size or unrecognised LN metastasis

A Japanese studyN = 5000• small tumors, regardless of ulcer status, and• nonulcerated tumors, regardless of size,did not have associated lymph node disease.patients with submucosal invasion less than 500 μm behaved similarly to patients who had completely intramucosaltumors.

Guidelines for ESR

All intramucosal tumors (any size) without ulceration Differentiated mucosal tumors of <3cm, with/without ulceration Limited submucosal invasion with size <3cm & without ulceration

Distal 1/3rd tumor :

Distal gastrectomyHemigastrectomy Subtotal gastrectomy

Middle 1/3rd tumor :

Subtotal gastrectomy Total gastrectomy

Proximal 1/3rd tumor :

Proximal esophago-gastrectomy (if R0 resection possible) but l/t symtomatic reflux

Total gastrectomy

Extent of lymph node dissection

D1Perigastric nodes (station 1-6)Conservative node dissection

D2D1 + left gastric, Common hepatic,celiac & splenic L.N.(7-11)Extended node dissection

D3D2 + Hepato-duodenal ligament, retropancreatic & mesenteric root (12-16)Super-extended lymphadenectomy

D4D3 + para-aortic and para colic LN dissection

Extent of nodal dissection D1 v/s D2most controversial area in gastric cancer management

Non japanese literatureD2 lymphadenectomy, when compared with a D1 dissection, has increased surgical morbidity, without a benefit in survival.

One criticism of the Western data is that although randomized, the D2 group did not differentiate between patients who had a splenectomy and those who did not. Subsequent subgroup analysis of the D2 without splenectomy group has shown results similar to the Japanese studies, with increased survival and no significant increase in morbidity.

Japanese literatureIncreased survival in patients undergoing a D2 dissection, with no increased or minimal increase in morbidity.

Resectable or not ? Involvement of other organ per se does not imply incurability, provided that it

can be removed ….Bailey and love’s short practice of surgery 26th ed.

Therapeutic nihilism should be avoided &, in low risk patient, an aggressive attempt to resect all tumor should be made. The primary tumor may be resected en bloc with adjacent involved organs (eg., pancreas, transverse colon, or spleen)

……Schwartz’ Princilpes of Surgery 10th ed.

A solitary metastatic nodule in liver is also no indication against curable resection.

..(CSDT) Current Diadnosis and Treatment, Surgery 14th ed.

Steps in Total gastrectomyLong mid-line incision or b/l subcostal incision (chevron)

Detachment of greater omentum from colon

anterior layer of mesocolon is dissected from mesocolonic vessels

Dissect upto inferior border of pancreas and divide Rt GE vessels

Dissect upto splenic hilum, ligate Lt. GE & short gastric

dissect lesser omentum from the undersurface of the Liver extending back to the right crus and mobilizing the right aspect of G-E junction.

Divide duodenum with GIA stapler

close the duodenal stump with interrupted horizontal 3-0 absorbable mattress sutures, essentially "dunking“ the duodenum.

Dissection of porta, hepatic artery, & celiac axis is completed from above down

Left gastric artery divided at its origin f/b clearance of right crus and celiac axis

dissection of all the tissue from Lt. crus & paracardial LNs

Mobilization of esophageal hiatus by detaching the peritoneal reflection from the diaphragm

Divide esophogus sharply by knife or scissors

Steps in Subotal gastrectomy1) Mobilization of the greater curvature

with omentectomy & division of left gastroepiploic vessels

2) lnfrapyloric mobilization with ligation of the right gastroepiploic vessels

3) Suprapyloric mobilization with ligation of the right gastric vessels

4) Duodenal transection5) D2 lymphadenectomy, with

dissection of the porta hepatis, common hepatic artery, left gastric artery, celiac axis, & splenic artery, and ligation of left gastric vessels

6) Gastric transection

Peri-operative Chemotherapy MAGIC trial

Randomised controlled study of 503 pts. With stage II or higher gastric cancer that compared perioperative chemotherapy with surgery alone.

CEF (Cisplatin, Epirubicin, 5-FU) - 3 cycles as neo-adjuvent CT- 3 cycles as adjuvent CT

5-yr survival, rate of local recurrence & distant metastasis were improved in CT group

UK National Cancer Institute trial

OEX (Oxaliplatin, Epirubicin, Capecitabine)

longer overall survival than with CEF and decreased incidence of thromboembolic phenomenon by substituting oxaliplatin for cisplatin

Intraperitoneal Chemotherapy (IPC)

Recurrence following curative resection is likely due to peritoneal carcinomatosis.

Systemic CT : blood-peritoneal barrier prevents the chemotherapeutic agents from achieving their cytotoxic effect.

IPC : administering high doses of chemotherapy directly to the peritoneum whilst reducing the systemic effects.

HIPC (hypothermia Intraperitoneal Chemotherapy )

increased risk of neutropaenia and intra-abdominal abscesses.

Adjuvent RadiotherapyINT(0116) trial demonstrates improvement in DFS and OS with post-operative chemoradiation than with surgery alone.

Radiotherapy is limited, due to its position near vital organs like kidney spinal cord, pancreas, liver & bowel.Stomach itself is highly sensitive, tends to bleed and ulcerate with EBRT.

Intraoperative radiotherapy (IORT)Takahashi & Abe in 1986, Japan randomized 211 patient IORT (25- 40 Gy) Vs surgery alone claims ↑ in 5-yr SR with IORT.

Chen & Song 1994, China randomized stage 3 & 4 patients for surgery with IORT Vs surgery alone claims ↑ in SR only in stage 3.

Sindelar & Tepper et al in 1993 , NCI (National Cancer institute) claims no survival benefit with IORT, but improvement in local recurrence (44% Vs 92%, p < 0.001).

Still it needs to define the role of IORT in gastric carcinoma.

Reconstruction after surgeryAfter total gastrectomy Roux-en-Y esophago-

jejunostomy

Division of jejunum with GIA stapler

end-to-side esopago-jejunostomy

full-thickness running suture

Placement of the EEA stapler through the divided loop

Completion of the stapled anastomosis and closure of the end of the loop with a stapler.

Jejunal loop should be at least 40 cm from the subsequent jejunojejunal anastomosis to minimize esophageal reflux.

Alternative reconstruction with the EEA stapler using a separate enrerotomy and end-to-end anastamosis

Jejunal pouch / Omega pouch

Pouch creation can be done safely without increased morbidity or mortality without significantly increasing the operative time.QOL was significantly better in pts with pouch reconstruction.Gertler R et al. Am J Gastroenterol 2009; 104(11):2838–51

make the pouch first by two passages of the GIA stapler and then perform the Esophago-jejunal anastomosis

Completed Roux-en-Y reconstruction

Post-op :Unless fever or ileus develops, the patient is allowed ice on the 1st day and can be given nutrient by the 5th day.

Any concern clinically for anastomotic leak can be confirmed by a Gastrografin Swallow, which is not routine

After Subtotal gastrectomy Loop gastro-jejunostomy (Bilroth II) or Roux-en-Y gastrojejunostomy

Stomach divided at greater curvature for 6-8 cm by knife (site of future anastamosis) and then completely divided with GIA stapler

Staple line inverted with suture

Anticolic Bilroth IIRetrocolic Bilroth II

Bilroth II

Standard technique for a two-layer, hand-sewn gastrojejunal anastomosis

After placement of corner sutures, a back row of interrupted 3-0 silk Lembert sutures is placed

jejunostomy is made with cautery

inner layer anastomosisis constructed in running, full-thickness fashion with 3-0 PDS

Anterior row of interrupted 3-0 silk Lembert sutures

After Subtotal gastrectomy Roux-en-Y gastrojejunostomy

jejunum is divided with GIA stapler approx. 20cm distal to the ligament of Treitz

end-to-side Roux-en-Y gastrojejunostomy is created with a Roux limb at least 45cm in length to avoid reflux

Laparoscopic resectionMeta-analysis of 5 randomized trials and 18 non –randomized comparisons of laparoscopic versus open gastrectomy came to following conclusions

Mean number of lymph nodes retrieved by laparoscopic surgery was close to that retrieved by open procedure

Less blood loss Lengthier operative times Conversion rate – 0 – 3% Significantly less postoperative morbidity after a laparoscopic procedure No difference in long term survival

Tanimura S et al. Surg Endosc 2008; 22(5):1161–4.Kawamura H et al. World J Surg 2008;32(11):2366–70

Revised Japanese Gastric Cancer Treatment Guidelines

Laparoscopy-assisted gastrectomy eligible for - stage IA and IB (T1N1, T2N0) cancers.

Kodera Y et al. J Am Coll Surg 2010; 211(5):677–86

Robot assisted SurgeryRobot assisted surgery (RAS)

Advantages• Provides articulated movement• Eliminates physiologic tremor• Steady camera platform allows more precise instrument

movement and dissectionsSong J et al. Ann Surg 2009;249(6):927–32

Palliative therapyPalliative surgery - Intention

To relieve pain and suffering without increasing morbidity or mortality

- Numerous palliative procedures• Gastro-enterostomy (enteric bypass)

Palliation – infrequent19% felt they benefitedPeri-operative mortality – high ….ReMine WH. World J Surg 1979;3:721-9

• Partial gastrectomy• Total gastrectomy

59% felt improved their QOL ….Monson JR et al. Cancer 1991;68:1863-8• Esophago-gastrectomy• Jejunostomy - for nutritional supplementation• acute refractory hemorrhage - Endoscopic techniques (laser argon ablation,

epinephrine injection) and arterial embolization• GOO – endoscopic dilation and stent placement (short term), CT, bypass with

gastrojejunostomy

Palliative Chemotherapy

CEF - Improve survival in patients with unresectable tumorAdverse reactions are common, with up to 50% of patients having severe neutropenia or GI complaints.

Cetuximab – epidermal growth factor receptor (EGFR) inhibitor

Trastuzumab (Herceptin) – human EGFR2 (HER2) antagonistbetter median survival and overall response rate than

CEF

One should remember1) 6 cm margin clearance of tumour is recommended.2) D2 lymphadenectomy is essential.3) Resection of greater & lesser omentum is necessary.4) Splenopancreatectomy only on indicated cases.5) For proximal lesion varying length of esophagus should be

excised.6) Judicious decision should be taken for total, proximal & distal

gastrectomy.7) All patient should receive chemoradiation.