Perforated gastric cancer - Forum

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John Dissector

Perforated gastric cancer - Ärzteforum

Post#1 »

Last night I had an unusual case--and I thought I've seen just about everything. A 42 year old black female presented to the ER with abdominal pain she associated with protrusion of a lump under her umbilicus about 5 hours previously, and my resident reported to me it looked like she had an incarcerated umbilical hernia which was so tender she would not allow examination--one episode of vomiting at home. On my exam, there was a very tender but soft subcutaneous mass at the umbilicus, at the superior end of a lower midline incision for a c-section 24 years ago--otherwise no prior surgery, on no medication except Goody powders over the past few weeks for abdominal pain she attributed to "heartburn". I was actually able to reduce this incarcerated incisional hernia, but could not get her to relax, and couldn't understand why it was so tender, until I realized she had a rigid abdomen--diffuse peritonitis--the hernia was just popping out from the rigidity and intra-abdominal pressure. We took her to the OR--her chest X-ray gotten after our exam prior to the OR showed-- surprise--free air under the left diaphragm.

At surgery--belly was full of turbid watery fluid and prurlent exudate over the epigastric organs--the body of the stomach was adherent to the underside of the left lobe of the liver and the underlying pancreas with an indurated mass palpated, and a 0.5cm hole spewing out corn and chittlins from the anterior gastric wall right where it adhered to the liver. I thought it looked like a perforated cancer which was locally extending into the liver and pancreas-- several enlarged but soft spongy nodes around the stomach and in the gastrocolic omentum--there was no other choice but to resect, so I decided to try a standard cancer resection, taking the omentum off the transverse colon, which was uninvolved--the jejunum at the ligament of Treitz was was socked right up into the mass where it densely adhered to the neck of the pancreas--a resection would have had to involve en bloc distal pancreatectomy from its neck distally along with en bloc wedge resection of the adherent portion of liver-- distally it was clear at the first part of the duodenum--and en bloc resection of the proximal jejunum, as an emergency procedure in the middle of the night in the face of significant contamination-- impossible to oversew the hole and get out--that area was like wet toilet paper in the middle of an indurated mass. The very proximal part of the stomach was also clear right at the GE junction on the lesser curve and at the level of the short gastrics on the greater curve. The transverse mesocolon and middle colic artery were also socked right up into this mass. The patient is stable at this point with a good urine output, antibiotics on board. She is also nice and thin. What would you all do at this point?


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surgery

Re: Perforated gastric cancer - Ärzteforum

Post#2 »

So what did you do?
Do you know for sure yet whether this is a malignancy?

Scalpel

Re: Perforated gastric cancer - Ärzteforum

Post#3 »

Based on your intra-operative findings, I suspect I would try to free the stomach from the liver, pancreas, and transverse colon. If this were possible, I would then resect the gastric mass (wedge resection) to grossly remove the mass and perforation. I would then close the stomach primarily. I probably would also place a feeding jejunostomy. I doubt that I would resect en block all adjacent structures. I am operating to save her life. I think the probability that I could cure her of gastric CA would be quite low (and if this were an inflamatory "phlegmon," then I would be increasing the magnitude of the procedure unnecessarily).

Antibiotic

Re: Perforated gastric cancer - Ärzteforum

Post#4 »

Cover the hole with something (omentum?) and get the hell out of Dodge.

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StSt

Re: Perforated gastric cancer - Ärzteforum

Post#5 »

Sounds bad. I would take a few biopseys and put a tube eg.red rubber catheter into the hole, or a foley to controll it and get out.

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Oncologist

Re: Perforated gastric cancer - Ärzteforum

Post#6 »

It would be nice to know if your'e dealing with cancer or not. I don't suppose you could get a pathologist in at that hour to do a frozen for you. Your note gave a subtle hint that maybe this wasn't cancer even though it looked like it. If you saw no metastatic disease, and could not get a frozen, then I would think maybe this could be bad ulcer disease. If you can't be sure of cancer you probably need to temper your extent of resection if there are other options.

The options include: (1) a tube or foley catheter, and omentum or falciform ligament, or jejunal patch-- you describe something that is probably too big for these options; (2) isolation of the injury by stapling across the stomach proximally and distally, placing a nasoesophageal tube, large sump or similar drains in or near the perforation, and probably a feeding jejunostomy tube, and waiting; (3) resect somehow or someway, but it doesn't sound like this would be easy and perhaps not even possible. If you can resect, I don't think I would try to hook things up.

If you get her over the sepsis, you've still got a long way to go, but if this is not cancer, you'll likely have a much easier time in 6-12 weeks. If this is cancer, it doesn't really matter.

John Dissector

Re: Perforated gastric cancer - Ärzteforum

Post#7 »

I got a smattering of responses, all involving the same thoughts going thru my head while staring at this mess at about 10pm with a chief resident across the table staring questioningly at me--I,m sure thinking something like "OK, big shot, show me how to get out of this one!" Well, tubing the hole or patching it in some way and punting was not an option, otherwise I'd gladly have done it--you had to be there. Both John Kennedy and Bob Goldman hit the nail on the head with regard to the conclusions I came to and what had to be done.

We got the pathologist to come in to do some frozens--a couple of the big nodes showed nothing but hyperplasia, and a good pieces of the indurated mass-like area where the stomach was socked up to the liver was only chronic inflammation. As I dissected, it was obvious I couldn't resect en bloc if I wanted (thank God!) since the neck of the pancreas was glued right to the mesenteric vessels--so I decided to just digitally peel the adherent stomach off the attached body of the pancreas and the liver, figuring if this was cancer, leaving gross disease behind would make no difference to her given the local extent of disease--this completely freed up the stomach, showing about 3/4 of the circumference of antrum and body was gone, only having been sealed off by the liver and pancreas, but no mass or anything that looked like tumor--I was not going to sew it back up because of doubt as to whether cancer was in this, and it looked like we'd be left with nothing in the way of a lumen anyway--so with clearance ofnormal tissue of only about 1cm before the pylorus distally and esophagus proximally I found myself having to do a total gastrectomy to get this out. The pancreatic bed was smooth and fibrotic, just like the bed of a penetrating ulcer--same with the liver bed--but a suspicious tumor-like excrescence was arising in the middle of it, making me wonder if this was a pancreatic Ca invading the stomach--a generous biopsy of this again showed no malignancy, just chronic inflammation--the gastrectomy was just about complete by this time, so we finished it, did a Roux-Y esophagojejunostomy hand- sewn--also, our dissection had devascularized the densely adherent transverse colon, so that came out and I pulled out an end right colostomy--I didn't want another suture line at that point, and the colon was full of mushy stool, altho I guess we could have reanastomosed that. The stomach specimen also showed no evidence of cancer on frozen--finals pending.

In retrospect, this appears to have been one horrendous gastric ulcer which had penetrated posteriorly into the pancreas and superiorly into the liver, the treatment of which required just what we happened to have stumbled into--I am so glad we didn't go with my original instinct and have done that major en bloc resection, which is why it was so important to have the frozens done--altho it is the only time I have ever had to do a total gastrectomy for benign disease, but it was the only thing I was able to do to get rid of the immediate problem. Again, the stomach was full of mush--she must have just eaten a huge meal--and bypass in my mind would have accomplished less than nothing, as the contamination would have just continued.

Well, she's doing great on POD #3, with bowel function returned-- I'll get a hypaque swallow on day #5, then feed, and hope the final path shows no surprises. Maybe we'll have to deal with an abscess in a week or two, but I hope not.

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A Doctor

Re: Perforated gastric cancer - Ärzteforum

Post#8 »

In spite of how bad it looks this could all be inflammation secondary to a benign neglected perforated ulcer. You cannot tell at this stage (frozen sections will not be helpful) and anyway, if this is indeed cancer, there is precious little you can do.

I think that the trauma concept of damage control is valid in this case as well. Just as in a bad trauma case, I would do as little as possible to prevent further spilage, including perhaps a gastrostomy in the proximal good stomach, and side duodenostomy. Get out, and return in 24-48 hours.

As the inflammation subsides, you should be able to see better, and make an intelligent decision. There is no point in trying to guess in the middle of the night, and possibly doing an unecessary huge operation for a benign disease.

As in trauma, damage control is not a cope out for the wimpy surgeon. It is often the best available option.

BTW, why did you attempt to reduce this "hernia"? the patient had a clear indication for surgery when you saw her. What would be gained from reducing it? would you not operate if it reduced and the patient didn't have peritoneal signs?

John Dissector

Re: Perforated gastric cancer - Ärzteforum

Post#9 »

Read my post--the patient had a diffusely rigid abdomen--the hernia had nothing to do with our decision to operate.

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Lady Surgeon

Re: Perforated gastric cancer - Ärzteforum

Post#10 »

During my residency, I initailly had a patient who presented with a tender (real tender) umbilical hernia. This turned out to have a perforated gastric ulcer. I thought this was interesting so I serched the liturature and found the first description of a tender hernia presenting as an underlying sign of peritinitis (descibed in the Br.Jr.Surg) concerned Afican children with umbilical hernias and T.B. peritonitis.

Call your pathologist in to do a frozen section (if not available proceed anyway). I would not do a major cancer operation without a diagnosis.If it is a perforated gastric cancer, curative resection is unlikely. I would close the hole in the stomach with omentum and make sure the nasal-gastric tube is working. Take a biopsy of the ulcer and get out. The pt. may be stable now but the next 4-5 days is the critical period.

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