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?