Surgery Pg No 156 -165

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Questions and Answers

Which type of early gastric cancer has the best prognosis?

Type IIa

Type III

Type IV

Type I (correct)

Type IV in the Bormann Classification represents ulcerated lesions infiltrating the gastric wall.

False

What mnemonic can be used to remember clinical features of gastric cancer?

LOADS

Type IIb is characterized by a _____ mucosa, submucosa, and muscularis propria.

flat Signup and view all the answers

Match the following advanced gastric cancer types with their descriptions:

Type I = Polypoid or fungating cancers Type II = Fungating or ulcerated with surrounding elevated borders Type III = Ulcerated lesions infiltrating the gastric wall Type IV = Diffuse infiltrating, leather bottle appearance Signup and view all the answers

What is the primary procedure performed in Billroth I Gastrectomy?

End-to-end gastro-duodenal anastomosis Signup and view all the answers

In Billroth II Gastrectomy, the duodenum remains open.

False Signup and view all the answers

List one component involved in the Roux-en-Y Gastrojejunostomy procedure.

Stomach, duodeno-jejunal flexure, closed duodenal stump, Roux limb, or bypass limb Signup and view all the answers

Billroth II Gastrectomy involves establishing an end-to-side gastro-________.

jejunostomy Signup and view all the answers

Match the following gastrectomy procedures with their descriptions:

Billroth I = End-to-end gastro-duodenal anastomosis Billroth II = End-to-side gastro-jejunostomy Roux-en-Y = Establish a gastric bypass Polya Reconstruction = Involves closing the duodenum Signup and view all the answers

What type of hernia occurs behind the Roux limb?

Peterson hernia Signup and view all the answers

Vagotomy is routinely performed for the treatment of gastric ulcers.

False Signup and view all the answers

What can happen if the motor branch to the gallbladder is cut during vagotomy?

Gallbladder stasis and stone formation Signup and view all the answers

The procedure that involves a longitudinal incision and transverse suturing to make the pylorus incompetent is called ______.

Pyloroplasty Signup and view all the answers

Match the following branches of the vagus nerve with their respective functions:

Coeliac axis branch = Supplies the stomach Ant trunk = Main trunk for parasympathetic supply Post trunk = Continues as post N. of Latarjet Crow’s foot = Supplies the antrum of the stomach Signup and view all the answers

Which procedure involves leaving a stomach pouch behind during surgery?

Pauchet Procedure Signup and view all the answers

H. pylori is solely responsible for gastric cancer.

False Signup and view all the answers

Name one toxic gene associated with H. pylori.

CagA Signup and view all the answers

The __________ enzyme allows H. pylori to survive in acidic environments.

urease Signup and view all the answers

Match the following conditions with their related outcomes:

Peptic ulcer = Stomach disease caused by acid damage Type B gastritis = Inflammation of the gastric lining Gastric cancer = Malignancy of stomach tissues MALTomas = Tumors associated with mucosal lymphoid tissues Signup and view all the answers

Which of the following statements correctly describes late dumping syndrome?

It may lead to rebound hypoglycemia due to excessive insulin. Signup and view all the answers

Early dumping syndrome is relieved by rest.

True Signup and view all the answers

What is a common dietary recommendation for managing dumping syndrome?

Avoid liquid with meals. Signup and view all the answers

In early dumping syndrome, symptoms usually occur within _____ minutes after food intake.

10-15 Signup and view all the answers

Match the type of hernia with its description:

Stemmer's Hernia = Bowel herniates through transverse mesocolon Peterson Hernia = Bowel herniates behind roux limb Signup and view all the answers

What does the Tis classification in the TNM system indicate about gastric cancer?

Carcinoma in situ. Signup and view all the answers

The minimum number of lymph nodes that should be removed during surgery for gastric cancer is 10.

False Signup and view all the answers

What surgical procedure involves the removal of 60-70% of the stomach?

Subtotal gastrectomy Signup and view all the answers

The primary site of metastasis for gastric cancer is the ______.

liver Signup and view all the answers

Match the following surgical margins with their respective distances:

Proximal Margin = 5 cm Distal Margin = Pylorus Signup and view all the answers

Which of the following is a risk factor for gastric cancer?

High alcohol consumption Signup and view all the answers

Men are more likely to develop diffuse gastric cancer than women.

False Signup and view all the answers

What type of gastric cancer is characterized by poorly differentiated tumors and signet ring cells?

Diffuse adenocarcinoma Signup and view all the answers

The Lauren classification categorizes adenocarcinoma into ______ and diffuse types.

intestinal Signup and view all the answers

Match the following characteristics with either Intestinal or Diffuse gastric cancer:

Risk Factors: Environmental = Intestinal Signet ring cells (+) = Diffuse Gland formation = Intestinal Decreased E-cadherin = Diffuse Signup and view all the answers

What is the primary goal of chemotherapy in gastric cancer treatment?

To reduce tumor size and spread Signup and view all the answers

Radiotherapy is used to enhance loco-regional recurrence of stomach cancer.

False Signup and view all the answers

Name one drug used in chemotherapy for gastric cancer.

5-FU or Cisplatin Signup and view all the answers

The _______ lymph node clearance involves the removal of stations 1-11.

DA Signup and view all the answers

Match the following treatments with their purposes:

Chemotherapy = To reduce tumor size Radiotherapy = To prevent loco-regional recurrence S1 chemotherapy = Oral fluoropyrimidine derivative Targeted therapy = Utilizing mutations like HER2 Signup and view all the answers

Which type of cancer is most commonly associated with Sister Mary Joseph's Nodule?

Stomach cancer Signup and view all the answers

Krukenberg tumor can be primarily associated with colorectal cancer.

False Signup and view all the answers

What is the main diagnostic method for detecting GIT cancers?

Endoscopic biopsy Signup and view all the answers

Virchow's Node is an enlargement of the left ________ lymph node.

supraclavicular Signup and view all the answers

Match the atypical presentations of GIT cancer with their descriptions:

Sister Mary Joseph's Nodule = Periumbilical metastasis Krukenberg Tumor = Bilateral ovarian metastases Blummer's Shelf = Pelvic/pouch of Douglas metastasis Virchow's Node = Left supraclavicular lymph node enlargement Signup and view all the answers

Which of the following is a complication associated with gastric reconstruction?

Gall stone formation Signup and view all the answers

Highly Selective Vagotomy results in maximum acid reduction.

False Signup and view all the answers

Name one nutritional complication that can arise after gastric reconstruction.

Iron deficiency anaemia Signup and view all the answers

The condition known as _____ is associated with an obstruction and perforation of the afferent loop in Polya reconstruction.

Afferent Loop Syndrome Signup and view all the answers

Match the types of vagotomy with their main characteristics:

Highly Selective Vagotomy = Less acid reduction and maximum ulcer recurrence Truncal Vagotomy + Gastrojejunostomy = Maximum acid reduction and complications Truncal Vagotomy + Antrectomy = Maximum acid reduction and least ulcer recurrence Signup and view all the answers

Study Notes

Japanese Classification of Early Gastric Cancer (Above Muscle Layer)

Type I: Protruded mucosa, best prognosis.
Types IIa, IIb, III, IV: Varying degrees of mucosal elevation or depression.

Bormann Classification of Advanced Gastric Cancer (Muscle Layer Involved)

Type I: Polypoid or fungating.
Type II: Fungating or ulcerated with elevated borders.
Type III: Ulcerated lesions infiltrating the gastric wall.
Type IV (Linitis plastica): Diffusely infiltrating, worst prognosis.
Type V: Unclassifiable.

Molecular Classification of Gastric Cancer

Chromosomal Instability: Intestinal pathology, best prognosis.
Genomically Stable: Diffuse pathology, worst prognosis.

Clinical Features of Gastric Cancer (LOADS mnemonic)

Lump.
Gastric outlet obstruction.
Anemia, anorexia.
Neodyspepsia (new onset GERD).
Silent presentation.

Gastrectomy Reconstructions

Billroth I: End-to-end gastro-duodenal anastomosis.
Billroth II (Polya): End-to-side gastro-jejunostomy.
Roux-en-Y: Gastric bypass, using a Roux limb and bypass limb (50cm jejunum).

Methods of Jejunal Mobilization

Antecolic: In front of the colon, risk of Peterson hernia (bowel herniation behind Roux limb).
Retrocolic: Behind the colon, risk of Stemmer's hernia (bowel herniation through transverse mesocolon).

Vagotomy

Indications: Duodenal ulcers, Type 2 and 3 gastric ulcers. No longer routine procedure (replaced by PPIs).
Branches: Celiac axis branch, anterior trunk, posterior trunk, posterior nerve of Latarjet, Crow's foot (supplies antrum), criminal nerve of Grassi (responsible for ulcer recurrence).
Motor branches to gallbladder (GB stasis if cut) and pylorus (impaired gastric emptying if cut).
Procedures often combined with gastrojejunostomy or pyloroplasty (longitudinal incision + transverse suturing).

Active Space Procedures for Gastric Ulcer

Type IV Active Space includes Pauchet, Kelling Madlener, and Csendes procedures.

Helicobacter pylori

Common cause of gastric ulcer disease.
CagA and VacA genes encode toxins.
Urease enzyme positive, survives acidic environment.
Pathogenicity: Peptic ulcer, Type B gastritis, gastric cancer, MALTomas. Slightly protective against esophageal adenocarcinoma and GERD.

Internal Hernias

Stemmer's hernia: Bowel herniates through transverse mesocolon.
Peterson hernia: Bowel herniates behind Roux limb.

Dumping Syndrome

Most common after Polya and Roux-en-Y procedures.
Early dumping: Hyperosmolar contents cause fluid influx (nausea, vomiting, bloating).
Late dumping: Rapid sugar absorption leads to insulin release and hypoglycemia (headache, sweating, tachycardia).

Dumping Syndrome Management

Dietary recommendations: small frequent meals, high fat and protein, avoid large meals, liquids with meals, and sugar-rich liquids. Octreotide considered if dietary changes fail.

TNM Classification of Gastric Cancer

Tis: Carcinoma in situ.
T1a: Invasion of lamina propria or muscularis mucosae.
T1b: Invasion of submucosa.
T2: Invasion of muscularis propria.
T3: Penetration of subserosal connective tissue.
T4: Invasion of serosa or adjacent structures. Most common site of metastasis: Liver.

Gastric Cancer Management

Multimodality: Surgery, chemotherapy (5-FU, cisplatin), radiotherapy.
Surgical margins: Proximal 5cm, distal to pylorus; R0 resection (microscopically free of disease). Followed by esophagogastrostomy.
Total or subtotal gastrectomy (60-70% or 30%).
Minimum lymph nodes removed: Gastric cancer (16), Esophageal cancer (15), Breast cancer (10), Colorectal cancer (12).

Japanese Lymph Node Stations for Gastric Cancer

D1 clearance: Stations 1-6.
D2 clearance (optimal): Stations 1-11.

Gastric Cancer Chemotherapy and Radiotherapy

Chemotherapy indications: Lymph node positive, muscle invasion, bulky lymph nodes, T3/T4.
Radiotherapy: To stomach bed, to reduce loco-regional recurrence.

Newer Modalities for Metastatic Gastric Cancer

PDL1 mutation: Pembrolizumab, Nivolumab.
HER2 mutation: Trastuzumab.
S1 chemotherapy: Tegafur (oral fluoropyrimidine derivative), oteracil, and gimeracil.

Gastric Cancer Prognostic Factors

Overall: Depth of invasion.
Operable: Lymph node status.

Gastric Cancer Risk Factors

Smoking, alcohol, smoked/preserved foods, H. pylori, Menetrier's disease, gastric resections.

Lauren Classification of Gastric Adenocarcinoma

Intestinal type.
Diffuse type.

Intestinal vs. Diffuse Gastric Cancer

Intestinal: Environmental risk factors, gastric atrophy, older patients, men > women, gland formation, hematogenous spread. Mutations: Microsatellite instability, APC gene mutations, p53, p16 inactivation.
Diffuse: Familial risk factors, blood type A, younger patients, women > men, poorly differentiated, signet ring cells, transmural/lymphatic spread. Mutations: Decreased E-cadherin, p53, p16 inactivation.

Atypical Presentations of Gastric Cancer

Sister Mary Joseph's nodule (periumbilical metastasis).
Krukenberg tumor (bilateral ovarian metastases).
Blummer's shelf (pelvic/Pouch of Douglas metastasis).
Virchow's node/Troisier's sign (left supraclavicular lymph node enlargement).
Irish nodule (left axillary lymph node enlargement).
Trousseau syndrome (migratory thrombophlebitis).
Leser-Trélat sign and tripe palms (dermatological presentations).

Gastric Cancer Investigations

Diagnosis: Endoscopic biopsy.
Staging: PET-CT (overall), EUS (T & N stage).
Most common site: Antrum. Higher incidence of proximal gastric cancer in the West.

Types and Complications of Vagotomy

HSV: Less acid reduction, maximum ulcer recurrence, fewer complications.
Truncal vagotomy + antrectomy: Maximum acid reduction, least ulcer recurrence, maximum complications.

Complications of Gastric Reconstruction and Vagotomy

Nutritional deficiencies (iron, B12, calcium).
Anastomotic leak (Billroth I > II).
Duodenal stump blowout.
Hemorrhage.
Bilious vomiting.
Peptic ulcers.
Afferent loop syndrome.
Post-vagotomy diarrhea.
Gallstone formation.

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Description

This quiz covers the classifications of gastric cancer including Japanese, Bormann, and molecular types, as well as their clinical features using the LOADS mnemonic. Additionally, it explores various gastrectomy reconstructions. Test your knowledge on this critical area of oncology.