CA stomach.ppt presentation following gastring outlet obstruction

Ca stomach

1. A 50 years lady with newly
onset dyspepsia
Presented
by
Dr Arindam
Das

2. Particulars of the patient
Name: Mrs. Kohinoor
Age/DoB: 50 years
Sex: Female
Religion: Islam
Marital status: Married
Occupation: Housewife
Address: Mugdapara, Mugda, Dhaka.
Reg No: 16994/56
Date of admission: 27/04/2019

3. Presenting Complaints
Upperabdominalpainanddiscomfort–6months.
Nauseaandvomitinginseveralepisodes-2months.
Lossofappetiteandweightloss-2months.

4. History of Presenting complaints
Patientstatethat,shedevelopedupperabdominalpain&
discomfortabout6monthsback.Painisdullachinginnature,
graduallyincreaseinintensity,nonradiating,initiallydoesnot
hamperdailyactivitiesbutlateritdoes.Pain&discomfort
aggravatedafterintakeoffoodsandsometimesrelievedby
takinganti-ulcerantorantacid.Painwasnotassociatedwithfever
withchill&rigor.

5. History of Presenting complaints
Shecomplainsofnausea&severalepisodesofvomitingforlast
3monthswhichisprofuseinamount,foulsmelling,projectile,
sourintastebutnotbilestained,containeddigestedand
undigestedfoodmaterialsthatshetookpreviously.
Shegavehistoryoflossofappetiteandsignificantamountof
weightloss(morethan10%ofpreviousBW)inlast3months.
Thereisnohistoryofhaematemesisandmelaena,cough,
haemoptysis,chestpain,bonepain,jaundice.
Shealsogavehistoryofconstipationforlast2months,but
bladderhabitsarenormal.Sheisnondiabeticandnormotensive.

6. History of Past illness
Nosignificanthistoryofpastmedical,surgicalillnessorany
trauma.

7. Drug & Allergy History
Hermedicationincludedantiulcerant,antacid,antispasmotic.
Shegavenohistoryofanyfoodordrugallergy.

8. Dietary History
Shegavenohistoryofexcessivesaltintakeandtakinganygrilled
orsmokedfoodsatregularbasis.
Sheneversmokedanddidnotdrinkalcohol.
Shetooklessamountofvegetablesandfruitsinherdailydiet.

9. Family and Social History
Mrs.Kohinoor,housewifelivesinbrickbuildhouseat
residentialareawithherfamilyhavingtwochild.
Herhusbandisabussinessman.
Herparentdiedoffnaturally.

10. General Examination
Appearance :Anxious,illlooking
Intelligence :Average
Co-operation :Co-operative
Bodybuilt :Average
Nutrition :Belowaverage
Anaemia :Mildlyanaemic
Jaundice :Absent
Oedema :Absent
Dehydration :Mildlydehydrated

11. General Examination
Cyanosis :Absent
Clubbing :Absent
Pulse :70beat/min
BP :100/70mmHg
Respiration :20beat/min
Temperature :36.6°c
NeckVeins :Notengorged
LymphNode :Notpalpable

12. Systemic Examination
Abdomen
Inspection:
Abdomenisscaphoidinshape
Flanknormal
Umbillicusiscentrallyplaced&inverted
Noengorgedvein
Novisibleperistalsis
Noscratchmarkispresent

13. Systemic Examination
Palpation
Temp : normal
Tenderness : present in epigastric region
Murphy’s sign : negative
Muscle gaurd : absent
Thereisanintraabdominallumpinepigastricregion,measuring
about3×3cm,haveirregularsurface,illdefinedborder,hardin
consistency,moveswithrespiration,freelymobileandfreefrom
overlyingskin.Thereisnoorganomegaly.

14. Systemic Examination
Percussion
Tympanicinallovertheabdomen.
Upper border of liver dullness: in 5th intercostal space on
right midclavicular line.
Shiftingdullnessandfluidthrill:absent
Auscultation
Bowelsound:present
Digitalrectalexaminationshowsno
abnormalities
Othersystemicexaminationrevealsnormal
finding.

15. Salient Feature
MrsKohinoor,50yrshousewifefromMugdapara,Dhaka
presentedwithupperabdominalpain&discomfortfor6months
whichisdullachinginnature,graduallyincreaseinintensity,
initiallydoesnothamperdailyactivities.Thereisnoradiationof
pain,norelationtofoodorfattymeal,nospecificaggravatingor
relievingfactorandpaindoesnotrelievedbytakingantiulcerant
orantacid.Painwasnotassociatedwithfeverwithchill&rigor.
Shecomplainsofnausea&severalepisodesofvomitingforlast
3monthswhichisprofuseinamount,foulsmelling,projectile,
sourintastebutnotbilestained,containeddigestedand
undigestedfoodmaterialsthatshetookpreviously.Shealsogave
historyoflossofappetiteandsignificantamountofweightloss
inlast3months.

16. Salient Feature
Thereisno
history of
haematemesis
andmelaena,

17. Salient Feature
Onabdominalexam,Abdomenisscaphoidinshape,flank
normal,umbillicusiscentrallyplaced&inverted,no
engorged
vein,novisibleperistalsis,noscratchmarkispresent.
Abdominal
temparaturenormal,tendernessoverepigastricregion,
muscle
gaurdabsent,Thereisanintraabdominallumpinepigastric
region,measuringabout3×3cm,haveirregularsurface,ill
definedborder,hardinconsistency,moveswithrespiration,
fixed
withunderlyingstructurebutfreefromoverlyingskin.
Thereis

18. Provisional Diagnosis
Gastric Outlet Obstruction
due to ……???

19. Carcinoma Stomach

20. Differential Diagnosis
1)GOO due to chronic duodenal ulcer
2)Pancreatic carcinoma

21. Investigation Profile

22. For the Diagnosis & Extension
Ultrasonogram of Abdomen.
Endoscopy of upper GIT and Biopsy.
Tumor marker-CEA.
CECT scan of abdomen.

23. For Assessment
Complete blood count
RBS
S. Creatinine
S. Electrolyte
S. Albumin
LFT
Blood grouping & Rh typing
Urine R/M/E
CXR
ECG

24. USG of Abdomen
Normal study

25. Endoscopy of Upper GIT
Oesophagus: normal
Stomach:Anulceroproliferativegrowthseenintheantrum
withoutletobstruction.Residualfoodmaterialsalsoseen.
Scopecouldnotbenegotiatedfurther.
Duodenum:couldnotbeentered.
Biopsy:taken.
Comment:suggestiveofGOOduetomalignantantral
growth.

26. Endoscopy of Upper GIT
picture

27. Histopathology Report
Fragmentofgastricmucosashowpoorlydifferentiatedmucin
secretingadenocarcinomawithulcerationofthesurface.

28. Tumor Marker
CEA: 1.12 ng/dl

29. CECT scan of abdomen
Stomachisdistendedandshowsresidualfoodparticles.Soft
tissuemassandirregularwallthickeningarenotedinthegastric
antralregionmeasuringabout50mm×55mm×50mmcausing
markedluminalnarrowing.Smallamountoforalcontrast
mediumhaspassedintothesmallgut.Perigastricfatplanesare
maintained.Nosizeablelymhadenopathyisdetected.

30. CECT scan of abdomen
picture

31. Complete Blood Count
Hb: 8.5 gm/dl
ESR: 41 mm in 1st hour
WBC: 11,000/cumm

32. Liver Function Test
S. Billirubin: 0.2 mg/dl
SGPT: 38 µ/L
Alkaline phosphatase: 85 µ/L
Prothombin time: 11 sec
S. Albumin: 2.7 gm/dl

33. Other Investigation
RBS: 4.84 mmol/L
S. Creatinine: 0.96 mg/dl
S. Electrolyte: Na-139mmol/l, K-3.6 mmol/l
Urine R/M/E: normal study
Blood group: O positive
CXR: normal study

34. Plan of Management
???

35. Lower Radical Gastrectomy with
Gastro-jejunostomy
Under General Anaesthesia

36. Operation Note
Informed consent in written form has taken.
Date & Time: 25th May 2019 at 8.50 to 10.50 am.
Name of Operation: Lower Radical Gastrectomy with
Gastro-jejunostomy
Indication: Adenocarcinoma antrum of stomach
Name of anaesthesia : GA
Name of Incision:Midline incision.

37. Procedure and Findings
Withallasepticprecautionlaparotomydonebymidlineincision.
Noascitis,livermetastasis,peritonealseedling,ovaryandpelvic
metastasisfound.Agrowthfoundatantrumofstomach
measuringabout5cm×5cminvadingserosa.Pergastric,
suprapyrolicandinfrapyloriclymphnodehugelyenlarged.
D1/D2lowerradicalgastrectomydonebyusinglinearcutting
staplingdevice.Gastrointestinalcontinuityisreconstitutedby
meansofaRouxloopofjejunumusinglinearcuttingstapling
device.
Specimensentforhistopathologicaleamination.
Draintubegiven.Abdomenclosedinlayer.Skinclosed
intrdermalywith2/0C/Bprolene.

38. Procedure & Findings

39. Procedure & Findings

40. Lymph Node Station

41. The Extent of Lymphadenectomy
The1sttiernodesareperigastricnodesclosetothetumorand
the2ndtiernodesincludebothnodesalongtheproimal
sectionofthearteriessupplyingthesectionofstomach
involvedinmalignabcyandothermoredistantpergastricnodes.
Foreample,3,4d,5&6arethe1sttiernodesforthiscase(antral
cancer)and7,8,9&1are2ndtiernodes.
D1gastrectomyimpliesexcisionofall1sttiernodes,aD2
gastrectomytheexcisionofall1stand2ndtiernodesanda
D2/D3gastrectomyimpliestheadditionalremovalofsome3rd
tiernodes.
FARQUHARSON’S Textbook of operative general surgery
10th edition, page no 308

42. Specimen

43. Histopathological Report
Sectionofstomachwallshowadenocarcinoma.Theanaplastic
cellsarearrangedinglandularpattern,clustersandsingly.These
haveinvadedwholethicknessofthegastricwallandreached
serosa.
Sectionoftheresectionmarginsarefreeoftumor.6outof8
lymphnodesrevealmetastaticdepositsofadenocarcinoma.
Comment:Adenocarcinoma,moderatelydifferentiatedwith
lymphnodalmetastasis.

44. Thank You