Kallu, a 60 years old male diagnosed to have carcinoma stomach. CT scan of abdomen showed a mass measuring 4 x 4 cm in the antrum with involvement of celiac nodes and right gastric nodes. Management of choice is –
Correct Answer: Subtotal gastrectomy
Description: Ans. is 'b' ie. Subtotal Gastrectomy Management of Gastric carcinoma Surgical resection of stomach is the only curative treatment. It is also the best way of palliation in non-curable cases. So it's done in almost every case. Exceptions to surgery are - patients who cannot tolerate an abdominal operation and patients with overwhelming metastasis. The surgical objective should be to remove the tumor, and adjacent uninvolved margin of stomach and duodenum, the regional lymph nodes, and, if necessary, poions of involved adjacent organs. Radical subtotal gastrectomy is the standard operation for gastric cancer. -It removes distal 75% of the stomach, including the pylorus and 2 cm. of duodenum, the greater and the lesser omentum and the associated lymphatic tissue. Reconstruction is usually by Billroth II anastomosis - For curative treatment, all the margins (proximal, distal and radial) should be negative and an adequate lymphadenectomy performed. Margins are checked by frozen section biopsy. Total gastrectomy with Roux-en-Y esophagojejunostomy is done (splenectomy is plus/minus) - for proximal gastric carcinoma - for extensive tumors (eg. Linitis plastica) to obtain negative margins for distal gastric carcinoma Esophagogastrectomy with splenectomy is done for tumor of the cardia. Adequate lymphadenectomy must be done in all curable cases. Adjuvant Chemotherapy (5-fluorouracil & leucovorin) + Radiation therapy - their role is not very well proven Gastric Ca is relatively radioresistant tumor and radiotherapy alone has no role in treatment. The best it can be used for palliation of pain and bleeding. So in this patient Kallu, curative treatment is done by radical subtotal gastrectomy. Involvemetn of lymph nodes is no indication against curative treatment. Schwaz writes - "It should be strongly emphasized that many patients with positive lymph nodes are cured by adequate surgery. It should also be stressed that often lymph nodes that appear to be involved with tumor turn out to be benign or reactive on pathological examination. Therefore therapeutic nihilism should be avoided, and in the low risk patients an aggressive attempt to resect all tumours should be made."
Category:
Surgery
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