4. Gastric Cancer

Easy description

1. Presented by: Ms. Elizabeth M.Sc (N) Asst. Professor, Dept of MSN, NNC, GNSU

2. Anatomy The stomach has 5 parts Cardia: The first portion (closest to the esophagus) Fundus: The upper part of the stomach next to the cardia. Body (corpus): The main part of the stomach, between the upper and lower parts. Antrum: The lower portion (near the intestine), where the food is mixed with gastric juice. Pylorus : The last part of the stomach, which acts as a valve to control emptying of the stomach contents into the small intestine.

3. The first 3 parts of the stomach (cardia, fundus, and body) are sometimes called the proximal stomach. Some cells in these parts of the stomach make acid and pepsin (a digestive enzyme), the parts of the gastric juice that help digest food. They also make a protein called intrinsic factor, which the body needs to absorb vitamin B12. The lower 2 parts (antrum and pylorus) are called the distal stomach. The stomach has 2 curves, which form its inner and outer borders. They are called the lesser curvature and greater curvature , respectively.

4. Blood supply Most of the blood supply to the stomach is from Four main arteries Left gasrtic artery Right gastric artery Right gastroepiploic artery Left gastroepiploic artery branch

5. Venous drainage Left and right gastric vein Right gastroepiploic vein Left gastroepiploic vein

6. Lymphatic drainage It has into four zones: Superior gastric Suprapyloric Pancreaticolienal Inferior gastric/subpyloric

7. Stomach has five layers: Mucosa Sub mucosa Smooth muscle layer Sub serosa Serosa

8. Stomach cancer begins when cancer cells form in the inner lining of stomach. These cells can grow into a tumor. Also called gastric cancer, the disease usually grows slowly over many years.

9. Causes

10. Clinical Presentation Common clinical Presentation: 3A”s: 1.Anaemia(due to bleeding from tumour) 2.Asthenia(septic absorption from the tumour) 3.Anorexia onset of early satiety, dyspepsia, epigastric discomfort

11. Specific symptoms depending on the site of tumour. Pyloric region - gastric outlet obstruction. Proximal region - dysphagia, hamaetemesis. Body of stomach - mass per abdomen(silent variety). Metastatic disease - jaundice, ascites

12. Sign Grossly Anemic, Cachexia, Epigastric mass, Virchows node Sister mary joseph node Krukenberg tumor Irish node

13. Stages of gastric cancer

14. Staging of Gastric Cancer T 1 - lamina propria & sub - mucosa T 2 - muscularis & sub - serosa T 3 - serosa T 4 - Adjacent organs N - no lymph node N 1 - Epigastric node N 2 - main arterial trunk M o - distal metastasis M 1 - distal metastasis

15. Spread of Gastric Cancer Direct Spread Blood-borne metastasis Lymphatic spread Transperitoneal spread

16. INVESTIGATIONS Full blood count LFT, RFT Stool examination for occult blood CXR Serum tumor markers (CA 72-4,CEA,CA19- 9)

17. Diagnostic study of choice - USG, CT, biopsy UGI endoscopy with biopsy, CT, MRI & USG Laparoscopy Upper gastro intestinal endoscopy - Diagnostic accuracy is 98% if upto 7 biopsies is taken. Laparoscopy: Help in assessment of wall thickness, metastases (peritoneum ,liver & LNs) Help in assessment of wall thickness, metastases (peritoneum ,liver & LNs) Detection of peritoneal metastases

18. Management

19. Initial treatment 1.Improve nutrition if needed by parentral or enteral feeding. 2.Correct fluid &electrolyte & anemia if they are present.

20. Approaches Though some superficial cancers can be treated endoscopically, gastrectomy is the most widely used approach Total gastrectomy - usually performed for lesions in the upper third (proximal) stomach Distal subtotal gastrectomy - performed for tumors in the distal (lower two-thirds) of the stomach

21. RADICAL GASTRECTOMY Remove the stomach +distal part of esophagus+ proximal part of duodenum + greater & lesser omentum + Lymph Nodes Oesophagojejunostomy with roux-en-y gastric bypass surgery

22. SUBTOTAL GASTRECTOMY Similar to total one except that the PROXIMAL PART of the stomach is preserved Followed by reconstruction & creating anastomosis ( by gastrojejunostomy, billroth II )

23. Billroth - II

24. PALLIATIVE SURGERY For pts 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/ recanalisation)

25. POSTOPERATIVE ORDERS Admit to PACU Detailed nutritional advise (small frequent meals)

26. Post-Operative Complications Leakage from duodenal stump. Secondary hemorrhage. Nutritional deficiency in long term.

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

28. Radiotherapy Postperative-radiotherpy: may decrease the recurrence.

29. Nursing Diagnosis Acute Pain Altered Nutrition: Less Than Body Requirements Risk for Fluid Volume Deficit Fatigue Risk for Infection Risk for Altered Oral Mucous Membranes Risk for Impaired Skin Integrity

30. Anticipatory Grieving Situational Low Self-Esteem Risk for Altered Sexuality Patterns Risk for Altered Family Process Fear/Anxiety Risk for Constipation/Diarrhea

31. Nursing Management Monitor nutritional intake and weigh patient regularly. Monitor CBC and serum vitamin B12 levels to detect anemia, and monitor albumin and prealbumin levels to determine if protein supplementation is needed. Provide comfort measures and administer analgesics as ordered. Frequently turn the patient and encourage deep breathing to prevent pulmonary complications, to protect skin, and to promote comfort. Maintain nasogastric suction to remove fluids and gas in the stomach and prevent painful distention.

32. Provide oral care to prevent dryness and ulceration. Keep the patient nothing by mouth as directed to promote gastric wound healing. Administer parenteral nutrition, if ordered. When nasogastric drainage has decreased and bowel sounds have returned, begin oral fluids and progress slowly. Avoid giving the patient high-carbohydrate foods and fluids with meals, which may trigger dumping syndrome because of excessively rapid emptying of gastric contents. Administer protein and vitamin supplements to foster wound repair and tissue building.

33. Eat small, frequent meals rather than three large meals. Reduce fluids with meals, but take them between meals. Stress the importance of long term vitamin B12 injections after gastrectomy to prevent surgically induced pernicious anemia. Encourage follow-up visits with the health care provider and routine blood studies and other testing to detect complications or recurrence .