Gastric cancer: choice of operation and antibiotics - Forum

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Resident

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

Post#11 »

Recently, with a similar situation, a 88 yo female also diagnosed
gastric ca. with a "bleeding" complication was scheduled for presumably "palliative" gastrectomy. Intraoperative finding showed a good size lesion (grossly 4-5 cm) on the anterior wall, too close to
GE junction to get a 6 cm margin. (+) peritoneal seeding.What do you do, assuming she is an OK surgical candidate 88 yo?
? It's wrong to operate, to begin with?
? Total gastrectomy? One, including my attd, feared M&M
? Big wedge excision, which we did, and left behind
a very ugly,and funny bottle-shaped deformity stomach remnant.


User avatar
Oncologist

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

Post#12 »

Marcel wrote:About the operation in this case let me be a devil's advocate.
Ofcourse total gastrectomy with a distal pancreatectomy are a "fun"
procedure and a "piece of cake" for us big surgeons. But it is associated
with a well documented high M &M. Is the latter justified? Does it
translates to a better survival rate and better quality of life? This
lady was not really "bleeding", David- a little iron over 6 months is not
a "great deal" . You know that gastric ca patients very rarely
exanguinate. You mentioned "palliation" but what are you really palliating
here?

You are experts in ca stomach- are you convinced that
radical surgery will really prolong this patient's life and it's quality-
ofcourse if she survives with God's helps- and without antibiotics- the
"second hit".

A. have done a perfect job for this lady, he gave her a chance of 25%
five years survival, compared to 0% five years survival if a lesser operation
or palliative procedure was performed. Any M&M will be acceptable in the
background of 0% five years survival. If complete resection (R0) is achieved,
extended resection for locally advanced gastric carcinoma provides survival
time, which is comparable, stage for stage, with survival rates observed after
R0 resection for cancer limited to the stomach.

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Surgeon

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

Post#13 »

Resident wrote:Recently, with a similar situation, a 88 yo female also diagnosed
gastric ca. with a "bleeding" complication was scheduled for presumably "palliative" gastrectomy. Intraoperative finding showed a good size lesion (grossly 4-5 cm) on the anterior wall, too close to
GE junction to get a 6 cm margin. (+) peritoneal seeding.What do you do, assuming she is an OK surgical candidate 88 yo?
? It's wrong to operate, to begin with?
? Total gastrectomy? One, including my attd, feared M&M
? Big wedge excision, which we did, and left behind
a very ugly,and funny bottle-shaped deformity stomach remnant.


Peritoneal dissemination in cancer stomach is a contraindication for any surgical intervention, you can diagnose it preoperatively by a rectal examination, or by laparoscopic inspection before
laparotomy. The worst thing to do in cancer stomach is to cut through malignant tissue, or to leave malignant tissue behind, local recurrence is very quick and is a terribly devastating event.
Unfortunately you have done the worst option to your patient.

Jorjo

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

Post#14 »

To answer your questions,I must say that we consider that the presence of
peritoneal seeding,P1 or P2, is a contrindication to any kind of surgical
procedure...And so it is...The outcome of patients in whom any resection
with anastomosis procedure is performed, is bad,with all sort of
complications and,at the the end,you have waisted lots of time,provoked too
much suffering and no significant survival is obtained...

Perhaps in front of an 88 y.o. female,with a well localized lesion of about
5 cms in diameter,with bleeding problems,in spite of peritoneal seeding,you
feel tempted to practice what you did : a big wedge excission and,even if
that has no oncological base,it might be enough for such a patient...Hope
she did well and no complications appeared.

Wired

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

Post#15 »

Marcel wrote:About the operation in this case let me be a devil's advocate.
Ofcourse total gastrectomy with a distal pancreatectomy are a "fun"
procedure and a "piece of cake" for us big surgeons. But it is associated
with a well documented high M &M. Is the latter justified? Does it
translates to a better survival rate and better quality of life?


In the CURATIVE (T1-3, N0-1/2, M0) situation, which this is not, a
total gastrectomy, no splenectomy, should always be done for proximal
tumours. In the PALLIATIVE situation for proximal tumours, I have to
agree with you: most are irresectable, and iron and the odd
transfusion palliates well. But, on occasion, there is a little
subset of tumour which is locally invasive, and apparently non
metastasizing, which comes out easily and safely, with prolonged
palliation. Its a case of intra-operative judgement and strategy, and "if I do
this, will she be home & eating in 10 days?" The patient
described is not one of those, I dont think,and your conservatism is
probabl;y good judgement.

A total gastrectomy is not "radical" surgery, it is merely the
removal of a handful more stomach; a lymphadenectomy or
removal of adjacent organs en bloc is. But here we descend into the
semantics and connotations of that word "radical".

Wired

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

Post#16 »

Wired wrote:
A total gastrectomy is not "radical" surgery, it is merely the
removal of a handful more stomach; a lymphadenectomy or
removal of adjacent organs en bloc is. But here we descend into the
semantics and connotations of that word "radical".


In your multiple prior publications on this topic you claimed that being
"radical" in term of lymphnode dissection is not beneficial. Is resection
of adjacent organs beneficial? What do you think about that Am J Surg
paper-quoted here by my honorable friend Mohammed to support adjacent organ
resections in T4 lesions?

User avatar
Surgeon

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

Post#17 »

Radical lymphadenectomy for gastric carcinoma has not withstood
the steely scrutiny of randomised trials.

There have been no trials examining whether adjacent organ removal is
of value [morbidity, mortality, survival, QOL] with gastric
carcinoma. Instead, there have been many publications comparing
patients who had [ie were able to have] adjacent organ removal, to
those who did not [ie were not able to have], both in the T4
category. I use these articles for teaching: "Now today we are
going to talk about SELECTION BIAS in Surgery...". The easy ones get
the op, the difficult ones dont; easy ones do well - ergo it is the
op.

Nonetheless, there is a tiny subset of patients (not defined by
histological type or grade) that appear to be locally invasive, and
not generally disseminating. We have all seen this in the breast,
too. Tail of pancreas, bit of colon, bit of liver, out with the
gastrectomy. Very unusual, I agree, but there are these cases.

You have just nudged me into going to our database to punch in
T4NXM0; SX; laparotomy, no SX.

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