Gastric cancer: choice of operation and antibiotics - Forum

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Grandpa Phil

Gastric cancer: choice of operation and antibiotics - Ärzteforum

Post#1 »

A 72 old woman presented with UGI bleeding. For the last 6 month on Fe
supplement for anemia. Endoscopy shows a 10cm crater on the lesser curve,
and biopsies show adenoCA. The patient is a small woman, rather skinny,
but reports no recent weight loss. Patient is otherwise healthy. She is
active. Does her own shopping and housework, and passes the two bags one
flight test with ease. She has a supportive family.

On exploration there is a 10 cm mass on the lesser curve right up to the
GE junction. The mass seems to penetrate the tail of the pancreas.
and there are a few soft nodes on the lesser curve. There is no other
evidence of spread. Celiac nodes are not enlarged.

In order to rescet all gross tumor with adequate margins, one would need
to do a total gasterctomy, splenectomy and distal pancreatectomy. The
tail of the pancreas lifts easily off the celiac axis, and, technically,
resection is not too difficult, although jejuno-esophageal anastomosis
will have to be performed fairly close to diaphragm.

How many of my esteemed for-surgeons.com colleugues would embark on the more
radical resection, and who would choose instead a lesser procedure such as
total or near total proximal gastrectomy with shaving the pancreas,
leaving tumor behind. Or perhaps just a gastrojejunostomy. It is
impossible to exclude the tumor without closing the GE junction.

The second question I have, is that 36h after the operation the patient is
taken back for bleeding. The source is a small arterial branch near the
superior border of the pancreas. This is controlled, and the patient is
stable. Would anyone continue antibiotics beyond the perioperative period,
without evidence of infection?


User avatar
Surgeon

Re: Gastric cancer: choice of operation and antibiotics - Ärzteforum

Post#2 »

Firstly, anything you do with a T4 tumour is palliative. Secondly,
she is bleeding, so you have to do something.

> In order to rescet all gross tumor with adequate margins, one would need
> to do a total gasterctomy, splenectomy and distal pancreatectomy

A total gastrectomy is no big deal, and in a thin person the spleen
and distal pancreas deliver easily out the wound, although" shaving
off" might be better in the palliative situation.

> near total proximal gastrectomy
This is a mess: total or nothing.

Or perhaps just a gastrojejunostomy.

Wont stop the bleeding, and she isnt obstructed anyway.

User avatar
A Doctor

Re: Gastric cancer: choice of operation and antibiotics - Ärzteforum

Post#3 »

The total gastrectomy en bloc with pancreas and spleen is the way to go as it
provides the best palliation as well as only chance of cure If the tumor goes
up TO the GE junction you should be able to mobilize the esophagus
sufficiently not to be right at the hiatus--I also make it a habit to assure
your proximal margin is free by frozen section before anastomosing.
Stop the antibiotic-- unlike above, this is not a matter of opinion but well
established fact, that there is no benefit, and some harm, to prolonging
prophylactic antibiotic coverage.

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