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GS20 General Surgery and Thoracic Surgery Stomach and Duodenum Toronto Notes 2019 Gastrointestinal Stromal Tumour
Neoadjuvant Chemotherapy in Advanced Gastric and Esophago-Gastric Cancer. Meta-Analysis of Randomized Trials
Int J Surg 2018;51:120-127
Study: Meta-analysis evaluating the effects of neoadjuvant chemotherapy on advanced gastric cancer.
Results: Neoadjuvant chemotherapy and resection reduces overall mortality at 3 and 5-years in advanced gastric cancer (RR = 0.74; 0.82 respectively). Morbidity and perioperative mortality rate are not influenced by NACT. Recurrence rate is reduced by NACT + surgery in EGC (RR = 0.80).
Extent of Lymph Node Dissection for Sdenocarcinoma of the Stomach
Cochrane Database Syst Rev 2015
Study: Systematic review and meta-analysis of the evidence that existed regarding the impact
of the three main types of progressively more extended lymph node dissection (that is, D1, D2 and D3 lymphadenectomy) on the clinical outcome of patients with primary resectable carcinoma of the stomach.
Results/Conclusions: Data suggested no significant difference in overall survival between D2 and D3 type dissection. There was no significant difference in overall survival between D1 and D2 type node dissection. In contrast, D2 lymphadenectomy
was associated with a significantly better disease specific survival compared to D1 lymphadenectomy but was also associated with a higher postoperative mortality rate.
Epidemiology
• mostcommonmesenchymalneoplasmofGItract
• derivedfrominterstitialcellsofCajal(cellsassociatedwithAuerbach’splexusthathaveautonomous
pacemaker function which coordinate peristalsis throughout the GI tract)
• 75-80%associatedwithtyrosinekinase(c-KIT)mutations
• mostcommoninstomach(50%)andproximalsmallintestine(25%),butcanoccuranywherealongGI
tract
• typicallypresentwithvagueabdominalmass,feelingofabdominalfullness,orwithsecondary
symptoms of bleeding and anemia
• oftendiscoveredincidentallyonCT,laparotomy,orendoscopy
Risk Factors
• Carney’striad:GISTs,paraganglioma,andpulmonarychondroma • TypeIAneurofibromatosis
Investigations
• pre-operativebiopsy(endoscopicultrasound):usefulforindeterminatelesions(notrecommendedif high index of suspicion for GIST)
• contrast-enhanced CT is preferred Imaging for screening and staging; MRI if IV contrast not feasible
Treatment
• surgicalresectionif>2cm;followwithserialendoscopyif<2cmandresectifgrowingorsymptomatic • localizedGIST
■ surgical resection with preservation of intact pseudocapsule
■ lymphadenectomy NOT required, as GISTs rarely metastasize to lymph nodes
■ consider adjuvant treatment with imatinib (Gleevec) if high risk of relapse (large, >4 cm with
significant mitotic activity)
• advanceddisease(i.e.metastasestoliverand/orperitonealcavity)
■ palliative intent chemotherapy with imatinib
■ metastectomy may be considered for liver limited disease
Prognosis
• riskofmetastaticpotentialdependson
■ tumour size (worse if >10 cm)
■ mitotic activity (worse if >5 mitotic figures or 50/hpf)
■ degree of nuclear pleomorphism
■ location: with identical sizes, extra-gastric location has a higher risk of progression than GISTs in
the stomach
• metastasestoliver,omentum,peritoneum;nodalmetastasesrare
Bariatric Surgery
• weightreductionsurgeryformorbidobesity
• indications:BMI≥40withoutillnessorBMI≥35with1+seriouscomorbidity(e.g.DM,CAD,sleep
apnea, or severe joint disease)
Surgical Options
• combinationmalabsorptiveandrestrictive
■ laparoscopic Roux-en-Y gastric bypass (most common, most effective; higher complication rates)
◆ small gastric pouch (restrictive), from distal stomach, anastomosed with Roux limb of small bowel (malabsorptive); connect to biliopancreatic limb to maintain digestive enzymes and bile
■ restrictive laparoscopic sleeve gastrectomy (only consider for severe obesity) ◆ creation of tubular stomach via removal of majority of greater curvature
■ laparoscopic adjustable gastric banding (modest expected weight loss, declining in popularity) ◆ inflatable silicone band around fundus, adjustable via subcutaneous port
• malabsorptive
■ biliopancreatic diversion with duodenal switch
◆ anastomosis of stomach to distal ileum, anastamosis of biliopancreatic limb to terminal Ileum
Complications
• perioperativemortality~1%(anastomoticleakwithperitonealsigns,PE)
• obstructionatenteroenterostomy(seeComplicationsofGastricSurgery,GS18) • staplelinedehiscence
• dumpingsyndrome
• cholelithiasisduetorapidweightloss(20-30%)
• bandabscess(iflong-term)
Surgery for Weight Loss in Adults
Cochrane Database Syst Rev 2014; (8):CD003641. Study: This is an update of a Cochrane review first published in 2003 assessing the effects of bariatric surgery and control of comorbidities. Conclusions: Surgery resulted in decreased BMI one to two years post-op. 3 RCTs found that laparoscopic Roux-en-Y gastric bypass achieved significantly greater weight loss and body mass index (BMI) reduction up to five years after surgery compared with laparoscopic adjustable gastric banding (mean difference -5.2 kg/m2; 95% CI -6.4 to -4.0). More patients experienced remission
of diabetes, however different definitions used. Risks of surgery include leaks, hernias, infection, pulmonary embolism, cholecystitis, and post- operative mortality.