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.

User avatar
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.

Proctologist

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

Post#18 »

Why do you need an RCT for this? It is clear that if you do nothing for
T4 lesions there will be no 5 year survivors. If you remove, you will get
some (up to 25% in some series, higher if nodes are negative and there are
some T4N0 patients). There is no deed to do an RCT, if the results of
one alternative are 100% certain.

Of course the patients are selected. The easy ones are done. Those with
large palpable lymphnodes are excluded. The best evidence for this is that
the rate if T4N0 lesions in these series is around 30%, highly unlikely to
be the figure in the T4 population at large.

The selection only means that the conclusions apply only to similarly
selected patients, ie relatively healthy patients where resection is
deemed technically easy and who have no bulky celiac nodes or positive
paraaortic.

Now even in the selected patients the operative mortality for T4's is
10-15%.

So the question becomes the following (for the selected case): does one
accept a 15% immediate mortality and say 25% chance of 5 year survival,
vs. no immediate mortality and survival in the range of 3 months to say
two years.

I believe the choice between the two belongs to the patient, not the
surgeon. It is a matter of values, not technical expertise.

I ask the patients before the operation about their preferences. If they
are risk-averse, as many of them are, I would not do a radical operation.
But if they accept the risk I would, if they fit the selection criteria.
I also document the discussion in the chart.

User avatar
الجراح

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

Post#19 »

Your observations are in my opinion absolutely correct. Conservatism dies
slowly especially in certain enviroments.Er deduces that I chose
Hartmann's procedure to protect myself rather than look after the
patients interest. This is not correct . The reason i chose Hartmann , is
that colonic Traumatic lesions are rare in our enviroment and nobody had
ventured for primary anastomosis( No local track record) .However , I
think that after all these discussions one can easily face any opposition
armed by a consensus of opinions( Viva free speech and exchange of
ideas).

User avatar
Lady Surgeon

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

Post#20 »

I'm not so sure about this. I try to do what is right for the patient and I
do try very hard to keep up to date: for-surgeons.com, other e-mail groups, meetings,
over 100 CME credits per year.

However, I still run into a lot of criticism from the local surgeons, who
don't even look at my Medline articles, textbook articles, for-surgeons.com and other
e-mail group notes. They consider them irrelevant to the discussion. Last
time, I finally had to tell them I was bringing my lawyer to any further
discussions. For some reason, this scared them. I think it also made them
see that I am a serious person and they should take me seriously. One local
surgeon told me privately and in front of the entire Medical Executive
committee that he was going to run me out of town. I'm still here close to 2
years later.

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