Download presentation on gastric cancer. Presentation on oncology on the topic "Cancer Prevention"

Registered annually in the world

800 thousand new cases and 628

thousand deaths.

The leading countries in

Japan, Korea, Chile, Russia,

China. They account for 40%

all cases.

Japan - 78 per 100 thousand people

Chile - 70 per 100 thousand people

24. TNM classification

T - tumor

TIS - intraepithelial cancer.

T1 - the tumor affects only the mucous membrane and

submucosal layer.

T2 - the tumor penetrates deeply, takes no more than

half of one anatomical region.

T3 - a tumor with deep invasion captures more than

half of one anatomical region, but not

affects neighboring anatomical regions.

T4 - the tumor affects more than one anatomical

department and extends to neighboring organs

1) distal subtotal resection

stomach (performed through the abdomen),

2) gastrectomy (performed

transperitoneal and transpleural

3) proximal subtotal resection

stomach (performed through the peritoneal and

via pleural access).

1. Polyposis cancer.

2. Ulcerative (saucer-shaped) cancer

3. Infiltrative and ulcerative tumor.

4. Scirrhous gastric cancer with a diffuse infiltrative type of growth.

Palliative surgery for gastric cancer

The operation is aimed at improving the general condition and nutrition of the patient, not

eliminating stomach cancer. Such operations are considered a bypass anastomosis between

stomach and small intestine - gastroenteroanastomosis, gastro- and jejunostomy.

With such an operation, the primary focus or cancer metastasis is removed

stomach. These operations include palliative resections, removal

metastasis and palliative gastrectomy.

Gastroenterostomy - treatment of stomach cancer by creating an anastomosis between

jejunum and stomach.

Gastrostomy is the insertion of a tube into the stomach through the abdomen.

wall to feed the patient.

Enterostomy - performed to create patency of the digestive

a path if there is no possibility of imposing of a gastromtomy, and also for food

sick.

According to Borrmann (2008) macroscopic

types of tumor growth are divided into

1) polypoid cancer - a tumor protruding into the lumen

stomach, on a broad base, with clear contours;

2) ulcerated form - a tumor that looks like an ulcer with

raised above the mucous membrane with dense edges,

with infiltration of the stomach wall around it;

3) ulcerative necrotic form - a tumor without clear

borders, goes to the unchanged wall of the stomach;

4) diffusely growing cancer without a noticeable tendency to

ulceration, borders of tumor growth

macroscopically indeterminate.

Most often cancer affects

pyloroanthral stomach (60%

observations);

On the lesser curvature, carcinoma develops in

20-25% of patients;

In the proximal section - in 10-15%;

On the front and back walls - in 2-5%

observations;

Total defeat is registered in 5%

patients.

N0 - no metastases

N1 - metastases in regional lymphatic

N2 - metastases in the extraligamentous lymphatic

apparatus of the stomach

M0 - no metastases

M1 - distant metastases

To study the histological structure of cancer

stomach currently used

International Histological

WHO classification (1982)

a) papillary;

b) tubular;

c) mucinous;

d) cricoid.

Glandular cell carcinoma (adenoacanthomas)

Squamous cell carcinoma

undifferentiated cancer

Unclassified cancer.

T - Primary tumor

preinvasive carcinoma: intraepithelial tumor

without invasion of the own mucosal membrane (carcinoma in

the tumor infiltrates the wall of the stomach to the submucosa

layer.

the tumor infiltrates the wall of the stomach to the subserous

shells.

the tumor grows into the serous membrane (visceral

peritoneum) without invasion into adjacent structures.

the tumor has spread to adjacent structures.

Intramural extension to the duodenum or

the esophagus is classified according to the greatest depth of invasion

in all localizations, including the stomach.

N - Regional lymph nodes

insufficient data to assess regional

no signs of metastatic disease

regional l / nodes

N1 there are metastases in 1-5 l/nodes

N2 there are metastases in 6-15 l/nodes

N3 there are metastases in more than 16 l/nodes

M - Distant metastases

not enough data to determine

distant metastases

M0 no evidence of distant metastases

there are distant metastases (Virchow,

Krukenberg,

Schnitzler,

peritoneal carcinomatosis, liver)

Standard (subtotal

distal resection of the stomach,

proximal resection

stomach, gastrectomy)

Extended (D2, D3)

Combined

Yu.E. Berezov 1976

20. Stage 3.

With cancer of the cardiac region (the initial part of the stomach)

symptoms of dysphagia (salivation, difficulty

during the passage of coarse food). Dysphagia increases as

progression of the disease and narrowing of the lumen of the esophagus. On this background

there is regurgitation of food, dull pain or a feeling of pressure behind

sternum, in the region of the heart or in the interscapular space. Cause

these symptoms may be stagnation of food in the esophagus, expansion of it.

With localization of cancer in the antrum (the final part of the stomach)

relatively early there is a feeling of heaviness in the upper abdomen,

vomiting of food eaten the day before, an unpleasant rotten smell of vomit.

For cancer of the body of the stomach (middle part of the stomach),

even with a significant size of the tumor, local symptoms of the disease

are absent for a long time, general symptoms predominate - weakness,

anemia, weight loss, etc.

3. Painful form of stomach cancer.

Often worried about pain in the upper abdomen, which can

give to the lower back and be associated with food intake.

Pain often continues for a long period

time, sometimes all day, may be aggravated by movement.

With stomach cancer, pain is not regular. They are

do not subside after eating, there are no "hungry" pains or their

seasonality. In some cases, with common forms

stomach cancer pain can be quite intense

character. When the tumor grows into the pancreas

or even deeper patients may complain of back pain.

Such patients are usually treated for sciatica,

neuralgia.

T1 - the tumor does not extend beyond the cardia;

T2 - the tumor occupies the cardiac region;

TK - tumor of the cardia extends to the esophagus and

body of the stomach.

Cancer detection from one stage to

the other increases, and at the same time

reduced life expectancy

patient, the likelihood of recovery.

Four stages can be identified

Only the gastric mucosa is affected.

Cancer treatment in this case is possible without

strip operation, with

using endoscopic techniques and

the use of anesthesia.

In this case, the treatment of stomach cancer has

the most favorable prognosis - 90% of cases

convalescence.

The tumor penetrates deeper into the mucosa

shell, and also creates metastases in

lymph nodes around the stomach.

Survival with cancer treatment at this stage

is 60-80%, but such cancer is detected

rarely.

The tumor does not affect only the muscle

stomach tissue, there are metastases in

lymph nodes.

Five year survival at

diagnosing the disease at stage 2 - 56%.

Cancer penetrates entirely into the walls of the stomach,

lymph nodes are affected.

Stomach cancer of the 3rd degree is detected

quite often (1 case out of seven), but

five-year survival in this case -

A cancerous tumor penetrates not only into the stomach,

pancreas, large blood vessels,

peritoneum, liver, ovaries and even lungs.

Cancer in this form is diagnosed in 80% of patients.

Only in 5% of cases, the medical prognosis

the life expectancy of the patient exceeds 5 years.

TxNxM1

survival in

depending on

Stage I - 97.8%

Stage II - 72.0%

Stage III - 44.8%

T. Kinoshita et al, 1998.

IA (early cancer limited to the mucosa

lining of the stomach) perform minimally invasive

endoscopic and laparoscopic interventions -

endoscopic mucosectomy or laparoscopic

resection of the stomach, subtotal resection of the stomach.

For stages IB, II, IIIA, IIIB and IV (T4N2M0)

perform lymph node dissection in volume D2

D3 and para-aortic lymph node dissection

improve treatment outcomes

(only at T4N2M0) stages -

combined treatment with

preoperative chemotherapy. Volume

lymph node dissection for subsequent surgery

does not exceed D2.

Comprehensive treatment includes

combination of operational

interventions with neoadjuvant

(preoperative) or

adjuvant (postoperative)

polychemotherapy, or

various options

chemoradiation treatment.

Various methods are currently being used

combined treatment with the use of pre-, intra- and postoperative radiation therapy. Radiation therapy in

mainly aims to prevent

locoregional relapses. In case of preoperative

exposure targets are clinical and

subclinical zones of tumor growth, with intra- and

postoperative irradiation - hypothetically

surviving viable individual tumors

cells or their complexes. Until now, with

combined treatment of patients with gastric cancer

mainly used two fractionation schemes

doses: classical fractionation (2 Gy 5 times a day)

week to a total dose of 30-40 Gy) and an intensively concentrated course of ICC (4 Gy 5 times a week until

total dose of 20 Gy, which, when converted to the regimen

equivalent to 30 Gy).

Another combination option

treatment - intraoperative radiation

electron beam after removal

tumors. Such an impact will

affordable practical oncological

institutions after widespread introduction in

practice of accelerating therapeutic

technology generating electron beams with

energy 8-15 MeV. At the same time, the dose

single irradiation can range from

15 Gy to 20 Gy.

Radiation treatment. Radiation treatment for stomach cancer failed

wide practical application due to the danger

extensive radiation damage to the abdominal organs. AT

some cases in patients with resectable tumors,

especially with localization in the cardioesophageal zone,

refused surgery or in the presence of contraindications

it shows the conduct of radiation therapy in radical

split doses. It is advisable to use

classical fractionation or dynamic

fractionation.

The same can be therapeutic tactics for cancer recurrence in

stomach stump. In these cases, combinations can also be used.

external irradiation with intracavitary. At large

volumes of destruction and the existing danger of decay

tumors, as well as in debilitated patients, irradiation is indicated

through lattice diaphragms in single doses of 3 Gy and SOD 6080 Gy under open areas.

If the unresectability of the process is obvious and without

surgical intervention, in the absence of

irradiation for polio purposes. In 1/3 cases after

irradiation, there is a temporary reduction in the tumor and

improvement of the patency of the cardia.

Chemotherapy. Chemotherapy is performed for primary unresectable gastric cancer, relapses and metastases

tumors, as well as after performing palliative

surgical interventions and trial laparotomies. More often

of the entire treatment, 5-fluorouracil (5-FU) and ftorafur are used

both in the form of monotherapy and as part of various schemes

polychemotherapy. 5-FU is administered intravenously every other day from

calculation of 15 mg per 1 kg of the patient's weight (750-1000 mg).

The total dose of the drug for the course of treatment is 3.5-5 g.

another technique is to administer the drug in the same

single dose, but with a week break. Duration

The course of treatment in these cases is 6-8 weeks. Repeated

courses are carried out with an interval of 4-6 weeks.

Ftorafur is administered (intravenously or orally) in the daily

a dose of 30 mg / kg, which is divided into two doses with an interval of 12 hours

(on average, 800 mg 2 times a day). The total dose for this

is 30-40 g. this drug is very convenient for

outpatient treatment, as it can be used

In "safe" patients with unresectable tumors

classical method in SOD 30-40 Gy and in parallel

daily intravenous administration of 250 mg 5-FU.last

can be administered every other day, then a single dose is increased to

500-700 mg. The total course dose of cytostatic in both

cases should not exceed 3-6g.

Stage 0

Stage IA

Stage IB

Stage IIIA T2 a/b

Stage IIIB T3

Stage IV T4

Stages of gastric cancer

any N

14. Background diseases or risk groups for developing stomach cancer

Nutrition factor

Storage Condition Factor

food

Helicobacter pylori

There is an assumption that food

play the role of a carcinogen in various

- be a carcinogen;

- be a solvent for carcinogens;

- turn into carcinogens during processing;

carcinogens;

- insufficient inhibition of carcinogens.

Currently, more and more attention

pay attention to the influence of Helicobacter pylori on

occurrence of stomach cancer. This is

due to reports of domestic and

foreign researchers who

noted an increase in the incidence

in individuals infected with data

microorganism.

WHO experts recognized: from morphological

point of view, there is a precancer, and

distinguish between precancerous conditions and

precancerous changes.

Precancerous condition - the concept

clinical and is characterized by those

diseases of the stomach, which are most

often precede the development of cancer.

Precancerous changes - amount

morphological features called

dysplasia, previous and concomitant

Studies have shown that the state

has no acid production

independent value. In occurrence

cancer: possible hypoacidity (20.2%),

anacidity (44.3%), normacidity (18.2%),

hyperacidity (18.2%).

In 60% of patients with primary gastric cancer in

the anamnesis indicates chronic

diseases; leading among them are

chronic gastritis - 76.7%, 12.4%

patients previously diagnosed

duodenal ulcer, 7% have gastric ulcer, 0.8% have polyps,

3.1% - previously operated stomach.

epithelial polyps

Downstream, EPs are subdivided into 1) non-neoplastic and 2)

neoplastic. Neoplastic - adenomas of the gastric mucosa. They are

are divided according to the macroscopic form of growth into: flat and papillary.

Occur against the background of existing metaplasia of the gastric mucosa.

The incidence of cancer against the background of neoplastic adenomas varies in

wide limits. Malignancy of flat adenomas occurs in 621%, papillary - much more often (20-76%).

Resection of the stomach

Cancer develops in the remainder. Reasons for delayed changes

over time are not entirely clear. However, the most likely factor

is an

basic

parietal

responsible for the production of hydrochloric acid. Against the backdrop of an increase in pH

gastric juice, metaplasia processes begin to develop in

mucosa of the remaining part of the stomach, which can be considered as

precancerous changes. Time of cancer development after gastric resection

ranges from 15 to 40 years.

Menetrier's disease

It is a rare disease and is characterized by the presence of hypertrophic

folds

mucous,

reminiscent

decline

acid-producing function, protein-losing enteropathy. Disease

is rare, of unknown etiology, and is treated symptomatically.

pernicious anemia

With a combination of pernicious anemia and atrophic gastritis, the risk of gastric cancer

rises to 10%. The pathogenesis of pernicious anemia lies in the production

antibodies against proton pump cells, pepsinogen producing cells and

internal factor of Castle.

Chronic stomach ulcer?

The question is debatable. The fact of the occurrence of cancer in the inflammatory

altered tissues of the edge of the ulcer (50s). However, further research

allowed us to note that only 10% of gastric cancer were combined with a chronic ulcer, in 75% it was primary gastric ulcer, which proceeded with ulceration. That. gastric ulcer connection

and RJ is not considered reliable.

8. Small signs of stomach cancer

First, stomach cancer has signs,

common to cancer.

Chronic fatigue.

Fast fatiguability.

Unexplained weight loss.

Secondly, the presence of early stomach cancer can

signal a complex of symptoms, or the so-called

syndrome of small signs.

Discomfort in the stomach after eating: bloating,

a feeling of fullness.

Frequent nausea, vomiting, slight salivation.

Pain in the epigastrium: aching, pulling, dull. May occur

periodically, often appear after eating.

Loss of appetite not motivated by other factors.

Frequent heartburn, difficulty swallowing food and liquids (if

the tumor originated in the upper part of the stomach).

Vomiting of stagnant contents (eaten a day or two ago);

vomiting "coffee grounds" or with blood,

loose black stools - signs of bleeding in the stomach,

requiring an urgent call for an ambulance.

weakness, fatigue

during the weeks and months

persistent decline and loss

appetite

stomach discomfort

progressive weight loss

persistent anemia

depression, apathy

9. Symptoms of stomach cancer largely depend on the location of the tumor.

to local manifestations

refer symptoms

lack of physical satisfaction

saturation,

dull pressing characteristic pain,

a feeling of fullness and fullness in

epigastric region,

decreased or lack of appetite,

aversion to meat, fish.

weakness,

weight loss,

weakness,

rapid fatigue from the usual work and lowering

interest in it (in 90%);

depression,

anemia associated with occult blood loss and tumor

intoxication. Sometimes anemia is the first sign

diseases.

In advanced forms of cancer, there is an increase

body temperature from subfebrile to high. Causes

fevers serve as infection of the tumor, the development

inflammatory processes outside the stomach.

neuralgia.

Clinical signs characteristic

for the initial form of gastric cancer, not

exist. It can leak

asymptomatic or manifest

signs of the disease, against the background

which it develops.

Early diagnosis of cancer is possible with

mass endoscopic

survey of the population. Gastroscopy

allows you to detect changes in

gastric mucosa with a diameter

less than 0.5 cm and take a biopsy for

verification of the diagnosis.

More likely to get stomach cancer

in a group of people with high

cancer risk. To factors

increased cancer risk

precancerous diseases of the stomach

(chronic gastritis, chronic ulcer

stomach, stomach polyps);

chronic gastritis of the stomach stump in

operated on for non-cancer

diseases of the stomach after 5 years or more

after resection of the stomach;

exposure to occupational hazards

(chemical production).

Clinical manifestations of cancer

stomach are diverse, they depend on

pathological background, on which

a tumor develops, i.e. from

precancerous diseases, localization

tumors, forms of their growth,

histological structure, stages

dissemination and development

complications.

a. Endoscopy

(fibrogastroduodenoscopy)

With endoscopic methods

research can visually identify the tumor.

At the same time, it is possible to estimate its size, the nature of growth,

presence of bleeding, ulceration, rigidity

mucous membrane of the stomach. It is also important that

during fibrogastroscopy, you can take a site

tumors for morphological examination

(biopsy). But, unfortunately, information

single biopsy most often does not exceed 50%

and to establish the exact morphological

diagnosis requires several

Changes in blood tests appear late

stages of stomach cancer. The most common manifestation of cancer

stomach in laboratory tests is anemia. Anemia

develops mainly due to bleeding from tissues

tumors, but also a certain effect on the development

anemia causes malabsorption of substances.

As anemia progresses, it will increase and

ESR.

A leukimoid reaction may develop. Wherein

the number of leukocytes in the blood will exceed 30,000,

myelocytes and myeloblasts appear.

One of the frequent manifestations in the analysis of blood in cancer

stomach and other forms of cancer is hypoproteinemia and

dysproteinemia.

The main study for gastric cancer is FGDS, which gives

the possibility of a detailed examination of the mucous membrane of the esophagus,

duodenum and stomach, and detection of a tumor, determination of its

X-ray of the stomach - effective in infiltrative forms of cancer.

Allows you to assess the functionality of the body, gives

the possibility of suspecting gastric cancer or the onset of recurrence of the tumor. Such

diagnostic method is necessary in order to carry out effective treatment in the future

stomach cancer.

Endoscopic ultrasonography - allows you to accurately examine the condition

all layers of the stomach and in 80-90% of cases accurately determine the depth of the tumor.

The direction of magnifying endoscopy occupies one of the leading places in

clarifying diagnosis of gastric pathology, as it allows to identify

minimal disturbances in the typical architectonics of the mucous membrane and to distinguish between

areas of intestinal metaplasia and dysplasia or the presence of neoplastic changes.

Improving endoscopic examination is in the direction of introducing

narrow-spectrum (NBI-endoscopy). These are high-tech methods that

allow early detection of gastric cancer, and

promote identification of the centers of a tumor against hron. stomach diseases.

Optical coherence tomography - designed to determine the depth

invasion into the wall of the stomach, esophagus or other hollow organ. This equipment

a new generation allows you to determine in detail the thickness of the affected tissue,

it is possible to recognize the germination of the tumor in the submucosal and muscle layers

stomach. Under the control of optical coherence tomography, tissue sampling is carried out

lymph nodes in the surrounding area.

Diagnostic laparoscopy is a surgical procedure that

performed under intravenous anesthesia by puncture in the abdominal wall

camera to examine the abdominal organs. This research is applied

in unclear cases, to detect germination in surrounding organs

neoplasms, metastases in the peritoneum and for taking a biopsy. This method is sometimes

essential for effective treatment of gastric cancer.

Gastric cancer and blood tests for tumor markers - proteins that

produced by the tumor and not present in the healthy body. With the aim of

CEA, Ca 19.9 and Ca 72.4 are used for cancer detection. However, they all have

low diagnostic value. They have found their use in patients for

metastasis detection.

X-ray diagnostics. Complete

examination should include x-ray and

radiography in vertical and horizontal

positions of the patient, in known and strictly

defined for each section and walls of the stomach

positions at different degrees of contrast

barium suspension and air. Necessary condition

is a dosed compression of the available departments

organ. Primary Contrast Technique

allows you to evaluate inaccessible palpations of the department

stomach, study their relief, identify the border

tumor infiltration. Completing the study

should be in conditions of "tight filling" to assess

wall configurations, definition of violation zones

infiltration.

Purpose: to determine the localization, extent of the lesion,

transition of the process to the esophagus and duodenum

intestine and the degree of their stenosis, size and growth

Videogastroscopy - visual examination of the stomach with

collection of material for histological examination.

Fibrogastroscopic examination allows

determine the localization, anatomical type of growth

In cases of endoscopic detection of any

changes in the gastric mucosa

perform multiple biopsies of all

suspicious areas. And with ulcers

forms of cancer, it is necessary to take a biopsy

material both from the ulcer itself and from its surrounding

mucous membrane. When the tumor is located in

biopsy of the lower or upper third of the stomach

multiple sections of visually unchanged

mucous membrane in the remaining 2/3 of the organ for

determination of background changes in the mucosa, which in

can significantly influence the choice

scope of surgery.

Morphological diagnostics. Research

should be subjected not only to biopsy specimens from the stomach, but

and liver, parietal disseminations obtained during

laparoscopy, as well as as a result of targeted

biopsies under ultrasound guidance.

It should be noted that in some cases it is not possible

receive morphological confirmation of the diagnosis

in the presence of obvious clinical and instrumental

signs of stomach cancer, which is especially common

in infiltrative tumors with predominant

distribution in the submucosal layer. Such

situations, preference should be given to active

surgical tactics - diagnostic laparotomy

with intraoperative clarifying diagnostics.

Ultrasound examination (ultrasound).

Ultrasound examination of the stomach consists of 3

stages: 1) transabdominal examination;

2) polypositional polyprojective study

stomach after filling it with degassed liquid

to improve the visualization of the walls of the organ;

3) the final stage is the study of the wall

stomach with an intracavitary ultrasonic sensor, with

which assesses the depth of invasion of the stomach wall

tumor, the state of the perigastric lymphatic

Laparoscopy. Laparoscopic diagnostics

carried out to determine the depth of the lesion

tumor of the stomach wall, in particular the exit to

serous membrane, detection of its spread to

neighboring organs and detection of ascites and parietal

disseminated. Comparisons of laparoscopic

data on the germination of the serous cover of the stomach with

morphological study data

of the resected stomach showed the reliability

method in 95% of cases.

Laboratory diagnostics. Blood test in

early period of the disease rarely reveal any

changes. Anemia usually develops secondary

due to constant blood loss, insufficient

digestibility of nutrients, in particular iron, with

achlorhydria, as well as intoxication. Change

composition of peripheral blood is most pronounced in

metastatic lesions in multiple organs and

most commonly seen with liver metastasis and

pancreas, less pronounced with

retroperitoneal germination of the tumor.

First of all, you should be aware of precancerous

diseases of the stomach, which can give the same

chronic gastritis, polyposis, chronic ulcer

Carcinomas should be differentiated from

nonepithelial and lymphoid tumors of the stomach,

tumor-like processes, secondary tumors, and

also inflammatory and other changes,

simulating stomach cancer (tuberculosis, syphilis,

actinomycosis, amyloidosis, etc.).

For cardioesophageal cancer,

differential diagnosis with diseases

esophagus, and primarily with achalasia.

19. ROUTES OF METASTASIS

Gastric cancer metastasizes predominantly

by the lymphogenous route. Also possible

hematogenous, contact and

implantation pathway.

In addition, there are combinations of all three

ways of metastasis.

The following is most often noted

first regional barriers are affected

(lymph nodes located in

ligaments of the stomach), then lymph nodes,

accompanying large arteries, feeding

stomach, then retroperitoneal and organs

abdominal cavity.

51. Treatment of gastric cancer

Treatment is surgical.

Gastric cancer is an absolute indication for

operations. Radical

intervention is resection

stomach or gastrectomy.

1) transection of the stomach, duodenum

and esophagus within healthy tissues;

2) removal in a single block with the stomach of three groups

lymph nodes that may be affected

metastases at a given localization of cancer;

3) ablastic surgery i.e. usage

a set of techniques aimed at reducing

possibilities of the so-called manipulation

dissemination.

Contraindications for surgery may

be oncological and general

character. Operation is contraindicated

with distant metastases in

liver, lungs, supraclavicular

lymph nodes, if present

large ascites. Contraindications

general is sharp

cachexia, severe concomitant

diseases.

The treatment of cancer is different from the treatment of other organs.

If with carcinomas in other organs, surgery

is done only when the usual

therapy, then the opposite is true for stomach cancer.

Only surgery can save

sick. This is explained by the fact that the signs of cancer

unstable and may not appear for months, eventually

the patient comes already at the moment when it began

phase of stenosis and metastasis.

Chemotherapy, despite its possibilities, rarely

helps to stop the development of metastases and destroy cancer

cells in adjacent organs.

Radiation therapy, which is used for most cancers

formations, in cases with the stomach is not carried out.

Medical treatment will no longer bring any

result, so the only way is the surgical path.

If the carcinoma is small, then do

resection of the stomach, removing most of it.

But in many cases, the stomach has to be removed completely,

at the same time, all affected lymph nodes are removed. During

operations, the esophagus is sewn directly to the intestine.

In addition to removing the tumor of the stomach, removal of lymph nodes and fatty tissue is performed.

fiber. Lymph node dissection makes it possible to significantly increase the 5-year

survival and reduce the number of relapses. All operations are performed

minimally invasive using laparoscopic techniques. Subtal resection

is done with a small tumor, which is located at the exit from the stomach, and

approximately 4/5 of the stomach is removed. The remaining cases are the removal of the stomach and

all areas in which lymph nodes with metastases are located, while

the esophagus is sutured to the small intestine.

Treatment with surgical radical intervention

subtotal proximal resection of the stomach;

gastrectomy;

subtotal distal resection of the stomach.

Subtotal distal resection

During this operation, ¾ of the distal stomach with a ligamentous apparatus is removed and

lymph nodes. The entire lesser curvature is removed.

Subtotal proximal resection of the stomach

This operation involves the removal of the entire lesser curvature of the stomach with

paraesophageal lymph nodes and lesser omentum, as well as

part of the greater omentum.

Treatment of gastric cancer with gastrectomy

With it, the complete removal of the stomach with the ligamentous apparatus is carried out,

omentums and all areas of metastasis.

If stomach cancer has spread to neighboring organs, do

extended combined resections and gastrectomy, and together

with complete or partial removal of the stomach, a part of the neighboring

sick.

Treatment tactics are decided individually in each

specific case at the MDT with mandatory participation

surgeon, anesthesiologist, radiologist and chemotherapist.

The main method of treatment for patients with stomach cancer is

surgical. In recent years, developing

principles and methods of combined complex

treatment. Radiation and drug therapy as

independent methods are used only when

contraindications for surgery in patients with

advanced cancer or severe comorbidities

diseases.

There are 3 main types of gastric cancer

gastrectomy

distal subtotal resection - removal

4/5 or more parts of the stomach.

proximal sutotal resection of removal of 4/5 or more parts of the stomach.

Indication for distal subtotal resection

stomach is exophytic cancer of the lower third

stomach. According to strict indications, this operation

allowed with small endophytic or

mixed form of growth in tumors of the pyloroanthral

department. In practice, such tumors do not occur

more than 1.5% of cases, which determines the low

the significance of these operations.

Proximal subtotal resection of the stomach

transperitoneal access is performed only when

exophytic tumor of the upper third of the stomach, not

extending to the socket of the cardia.

Gastrectomy is performed for cancer of any

macroscopic form of growth,

locally advanced tumor, and

subtotal or total defeat

organ. However, before the formation

anastomosis needs urgent

morphological study of the remote

stomach to make sure

absence of tumor cells along the line

resection of the stomach and esophagus to avoid

continued tumor growth.

Today, the search for new surgical approaches continues,

allowing hope for improvement of remote

results of gastric cancer treatment. One of the ways to solve

given problem is the execution of extended and

combined surgical interventions.

Surgical approaches when lymph nodes are removed

nodes only with their macroscopic changes, should

examination of the lymph nodes after surgery

allows you to establish that "intact" lymph nodes

affected by cancer metastases in 57.1% of cases.

Given the large number of lymph nodes,

potentially capable of metastasizing,

it is impossible to establish true lymphogenous

metastasis, and, consequently, the stage of tumor

process without the most complete removal and study

all regional lymphatic collectors, that is, without

performing extended lymph node dissection.

does not exceed D2.

fractionation.

inside.

Operational

Combined

Comprehensive

Possibility of complete removal of the tumor

Absence of distant metastases:

liver (H1-H3), Virchow, Krukenberg,

Schnitzler, S.M. Joseph, carcinomatosis

peritoneum (P1-P3),

Functional portability

intervention

Indications for subtotal distal resection

Exophytic

radiological

endoscopic

signs

infiltrative growth.

Lack of transition to the corner of the stomach (lower third

no multicentric growth foci.

no metastases to paracardial lymph nodes

zones, retroperitoneal, splenic, in the region of the celiac

trunk, at the hilum of the spleen.

The absence of a massive exit of the process to the serous

lining of the stomach

Proximal subtotal resection of the stomach

can be performed with the size of the tumor

up to 4 cm, with localization in the proximal

department without spreading to the upper

third. And it is mandatory

resection of unchanged visually and

palpation of the stomach wall by 2 cm

distal to the determined border of the tumor

with a superficial character

growth, 3 cm with exophytic and 5 cm with

endophytic and mixed types of growth.

The surgical method remains the gold standard in

radical treatment of gastric cancer, allowing hope for

full recovery.

Radical operations for gastric cancer include mandatory

monoblock removal of regional lymph nodes

nodes.

The concept of preventive one-piece removal of zones

regional metastasis along with primary

focus in gastric cancer is associated with the name of the Japanese surgeon Jinnai

(1962), who based on his results

considered such an amount of intervention as

radical. From that moment on, the extended radical

lymph node dissection as a mandatory integrated stage

operation has become a generally accepted doctrine

surgical treatment of gastric cancer in Japan.

Different types of lymph node dissection have found their own

reflection in the classification of the volume of intervention, on

based on the last stage to be removed

metastasis.

TYPE OF SURGICAL INTERVENTION

Standard gastrectomy (SG) D1 at volume

lymph node dissection N1.

Standard radical gastrectomy (SRG) D2 for

volume of lymph node dissection N1-2.

Extended radical gastrectomy (ERG) D3

volume of lymph node dissection N1-3.

Chemotherapy - neoadjuvant, adjuvant,

perioperative, adjuvant chemo and/or

radiotherapy, hyperthermia

intraoperative intraperitoneal

chemotherapy (GIHI), early

postoperative intraperitoneal

chemotherapy

Self-administered chemoradiotherapy

Preoperative and intraoperative

radiation therapy

Stage 1 - 74.0% (D1), 92.4% (D2.3)

Stage 2 - 66.1% (D1), 75.9% (D2.3)

Stage 3 - 24.6% (D1), 47.7% (D2.3)

Stage 4 - 0% (D1), 16% (D2,3)

Japanese Gastric Cancer Association,

1992

43. Surgical treatment of gastric cancer

access),

In determining the indications for surgical treatment, the doctor should

be guided by objective data of clinical and

physical examination of the patient, based on which

preoperative clinical staging

disease and evaluate functional operability.

Necessarily preoperative morphological

biopsy study, which, in combination with

characteristic of the type of growth allows you to plan

adequate amount of surgery

All patients require X-ray and

endoscopic research. Just a combination of both

methods allows to assess the nature of tumor infiltration

in the stomach with a possible transition to adjacent structures

Gastrointestinal tract along the length (esophagus, duodenum) and

classify the type of tumor growth, which is

an integral indicator that combines data

x-ray and endoscopic examination.

X-ray examination. Is an

the main in determining the localization and

the extent of damage to the organ wall.

It is advisable to carry out in a complex way, using tight

padding and double contrasting. First

most informative in exophytic tumors,

the second (including the combined use of barium with

effervescent substances against the background of wall relaxation

stomach with the use of glucagon) - allows you to evaluate

intramural infiltration of the gastric wall and

involvement of adjacent structures throughout. Should

note that all patients with identified ulcers

stomach must additionally pass

endoscopic examination with morphological

verification of mucosal changes in the ulcer area.

To judge the nature of the ulcer only according to the data

X-ray examination is not possible.

Endoscopy. Is one of

the most informative methods for diagnosing gastric cancer, because,

it determines: the boundary, nature and form of growth

tumors; spread of infiltration to the esophagus;

presence of complications. In some cases, it is performed

chromendoscopic examination. For this mucous

stained with 0.1% indigo carmine solution or

methylthioninium chloride. The method allows more

establish in detail: the boundaries of infiltration even

with endophytic spread along the submucosal

layer; the presence of a synchronous tumor and intramural

dust-like metastases in the wall of the stomach at the level

submucosal layer.

Ultrasound of the abdominal organs, retroperitoneal

space. Mandatory research method

patients with RJ. Women must include

pelvic organs.

Endoscopic Ultrasound

(EUSI). A promising method of complex diagnostics

intramural and lymphogenous prevalence

tumor process. The method accumulates

endoscopic and ultrasound capabilities

research, which allows with high reliability

determine intramural extent

process, including: the depth of invasion into the wall, the presence

metastases in l / y, not only perigastric, but also

retroperitoneal and even para-aortic and performed

puncture for the purpose of morphological verification.

CT. Its place in the preoperative diagnosis of gastric cancer

remains undefined. Recently

application of spiral tomographs and methods

contrasting combined with the possibility

3D imaging has improved resolution

method ability.

Extracorporeal ultrasound. Depth estimation possible

gastric wall invasion and preoperative

definition of the symbol st. High enough

sensitivity (76.3%). Better reliability at

tumors in the muco-submucosal layer (stT1 - 87.1%) and

with germination of the serous membrane and involvement

surrounding structures (stT3/T4 - 76.9%). In others

cases, overdiagnosis is possible.

Laparoscopy. To date

laparoscopic examination is

obligatory in preoperative staging of gastric cancer and

should be performed routinely in all patients.

the frequency of intraperitoneal dissemination of gastric cancer,

undiagnosed by non-invasive methods

research, as well as the suspicion of

subcapsular formations in the liver, identified

with ultrasound and CT scans.

Despite a significant increase

resolution of diagnostic

procedures, development and optimization of methods

research, final conclusion

the true prevalence of the process with

possibility of radical

operations can often be obtained only with

intraoperative revision.

Combined

Exophytic

radiological

endoscopic

signs

lining of the stomach

nodes.

metastasis.

lymph node dissection N1.

8. Risk factors for stomach cancer

High intake of unrefined fats

Nutritional features (little animal protein,

fresh herbs, vitamin C, trace elements,

milk and dairy products, predominance

vegetable products with excess starch,

consumption of hot food, irregular

Smoking, especially in combination with alcohol

reverse - zinc, manganese

One of the reliable causes of cancer

stomach are N-nitrosamines, often

endogenous. Starting point of pathogenesis

is a decrease in gastric acidity

juice, with chronic gastritis,

contributing to the development of pathogenic flora,

with an increase in the synthesis of nitro compounds.

15. Background diseases or risk groups for developing stomach cancer

epithelial polyps

Resection of the stomach

is an

removal

basic

parietal

Menetrier's disease

mucous,

reminiscent

convolutions

Identification of precancerous conditions and regular medical examination.

Diet. Reduce the consumption of fatty, salty, smoked and fried foods, spicy and

spicy foods, do not abuse alcohol, avoid preservatives and

dyes.

Be more attentive to the vegetables you eat, they can potentially

Observe the measure in the use of drugs (especially analgesics, antibiotics,

corticoids).

Reduce the negative impact of the environment, harmful chemicals

connections.

Eat more fresh foods rich in vitamins and

trace elements, as well as dairy products.

Follow a normal diet, avoiding too long breaks

between meals, overeating.

Primary prevention of gastric cancer in

generally repeats that for others

malignant tumors.

The secondary has a number of features. She is

based on early detection and

adequate treatment of precancerous

disease and early gastric cancer.

The main issue in this regard is

active identification of patients with this

pathology. Introduction of screening

programs.

Most Favorable Results

surgical treatment of stomach cancer

can be obtained through treatment

early forms of cancer.

If only the mucosa is affected

membranes 5-year survival

reaches 96-100%,

with mucosal injury and

submucosal layer - 75%.

Figure 1. Radiograph for stomach cancer. With tight filling, the contour of the angle of the stomach is uneven, with a slight retraction (indicated by a black arrow). Along the lesser curvature of the antrum

– rigid platform (indicated by a white arrow).

Figure 2. Radiograph for gastric cancer. With double contrasting - convergence of mucosal folds to the flattened wall of the stomach (indicated by an arrow)

Stomach cancer

Figure 1. Radiograph for stomach cancer. With tight filling, the distal section is deformed like a rigid tube, its contours are uneven, the walls are rigid, the lumen is not narrowed.

Figure 2. Radiograph for gastric cancer. With double contrasting, circular infiltration of the distal stomach is observed with its spread to the lesser and greater curvature of the stomach (indicated by arrows)

Stomach cancer

A symptom of atypical relief is a defect that reflects the tumor node. The shape of this node is uneven, irregular, the outlines are vague.

A typical sign of a change in relief in gastric cancer is a persistent spot, or depot of barium, due to ulceration of the tumor. The shape of the spot is wrong. The contours are uneven, fuzzy.

In some cases, radiographs reveal powerful hyperplastic, expanded, randomly located folds with a “clipping symptom” or, conversely, the absence of folds

- "symptom of a bald area"

X-ray for stomach cancer. With tight filling, the contour of the lesser curvature of the lower third of the body is uneven (indicated by an arrow), the contour of the greater curvature is without visible changes

Small stomach cancer

Fig.1. X-ray for stomach cancer. With tight filling, the angle of the stomach is straightened, on the lesser curvature, a rigid platform with a notch symptom is determined (indicated by an arrow).

Fig.2. X-ray for stomach cancer. The wall of the antrum is thickened due to intramural infiltration (indicated by an arrow).

Small stomach cancer

Fig.1. X-ray for stomach cancer. With dosed compression, the contour of the lesser curvature of the lower third is uneven, undermined, a flat ulceration is determined that does not go to the contour (indicated by arrows).

Fig.2. X-ray for stomach cancer. Near the angle of the stomach, there is a thickening of the stomach wall due to intramural infiltration (marked with an arrow).

Pyloric stenosis

The main causes of pyloric stenosis:

1. Scarring in the pyloric area

2. Stricture after chemical burn

3. Neoplasm at the outlet of the stomach

4. Germination of the tumor from neighboring organs. Stages of stenosis:

1. Forming stenosis: there is no clear CC, on x-ray examination the stomach is not dilated, peristalsis is normal or somewhat increased, the stomach is completely emptied

2. Compensated: the stomach is of normal size or somewhat dilated, on an empty stomach - liquid, peristalsis is weakened. The evacuation of the contrast mass is delayed by 6-12 hours. EGDS reveals a pronounced cicatricial deformity of the pyloroduodenal canal with a narrowing of the lumen to 0.5 cm

3. Subcompensated stenosis: a decrease in the tone of the stomach and its moderate expansion is determined, on an empty stomach it retains fluid. Peristalsis is weakened, barium lingers in the stomach for 12-24 hours. With endoscopy - stretching of the stomach, narrowing of the lumen of the pyloroduodenal canal to 0.3 cm

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Epidemiology

Gastric cancer is the second most common cause of death from malignant neoplasms. The highest incidence is recorded in Japan, China, Korea, countries of South and Central America, as well as in Eastern Europe, including the former Soviet republics. In the Russian Federation, about 40 thousand primary patients with stomach cancer are registered annually, 35 thousand die. The incidence is 28.4 per 100 thousand population. Since the middle of the 20th century, there has been a decrease in the incidence of gastric cancer worldwide due to patients with cancer of the distal stomach of the intestinal type, while the proportion of cardia cancer has been growing, and most rapidly among people under 40 years old.

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Epidemiological classification according to Lauren

Intestinal type: The tumor has a structure similar to colorectal cancer and is characterized by distinct glandular structures consisting of well-differentiated columnar epithelium with a developed brush border. Diffuse type: the tumor is represented by poorly organized groups or single cells with a high content of mucin (cricoid) and is characterized by diffuse infiltrative growth.

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Epidemiology of stomach cancer

Peak incidence 50-60 years Men are 2-12 times more likely to get sick Localization: more often distal. However, there is a trend towards an increase in proximal and cardio-esophageal cancer, especially in Europe and America Asia - distal cancer is much more common (better treatment results and prognosis!)

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Epidemiology of gastric cancer in Europe

2006 - 159,900 new cases and 118,200 deaths, which ranks fourth and fifth in the structure of morbidity and mortality, respectively. Men get sick 1.5 times more often than women, the peak incidence occurs at the age of 60-70 years.

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Biography

Genus. April 23, 1867 in Silkeborg, Denmark. He studied bacteriology under the guidance of R. Koch and E. von Behring, worked together with Carl Salomonsen at the University of Copenhagen. A doctoral thesis in the bacteriology of diphtheria was completed in 1895, and in 1900 a university professor of pathology. Introduced Behring's serum for the treatment of diphtheria in Denmark and investigated the relationship between outbreaks of tuberculosis in cows and the spread of this disease in humans. Rat tuberculosis and gastric cancer with Spiroptera neoplastica (Gongylonema neoplasticum). In the 1920s, he conducted a comparative experimental study of cancer caused by coal tar, Spiroptera neoplastica and clinical manifestations. The combination of external influences with a genetic, not general, but organ predisposition to cancer. Nobel Prize in Medicine and Physiology in 1926. “For the first time, it has become possible to experimentally transform normal cells into malignant cells of cancerous tumors. Thus, it was convincingly shown not that cancer is always caused by worms, but that it can be provoked by external influences ”(W. Wernshtedt). He died in Copenhagen on January 30, 1928 from rectal cancer.

Slide 10

Etiology

A. Dietary risk factors Excessive consumption of table salt and nitrates Lack of vitamins A and C Consumption of smoked, pickled and dried foods Preservation of food without using a refrigerator Quality of drinking water B. Environmental and lifestyle factors Occupational hazards (rubber, coal production) Tobacco smoking Ionizing radiation History of gastric resection Obesity B. Infectious factors Helicobacter pylori Epstein-Barr virus

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D. Genetic factors Blood group A (II) Pernicious anemia Familial gastric cancer Syndrome of hereditary diffuse gastric cancer (HDGC). Hereditary non-polyposis colorectal cancer Li Fraumeni syndrome (hereditary cancer syndrome) Hereditary syndromes accompanied by polyposis of the gastrointestinal tract: familial adenomatous colon polyposis, Gardner syndrome, Peutz-Jeghers syndrome, familial juvenile polyposis E. Precancerous diseases and changes in the gastric mucosa Adenomatous polyps of the stomach Chronic atrophic gastritis Menetrier's disease (hyperplastic gastritis) Barrett's esophagus, gastroesophageal reflux Gastric epithelial dysplasia Intestinal metaplasia

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Etiological factors of stomach cancer

Nutrition Bile reflux Helicobacter pylori Genetic disorders Risk factors - exogenous sources of nitrates and nitrites, endogenous formation of nitrates, increased salt intake, food storage, alcohol. Protective factors - antioxidants and beta-carotene.

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Helicobacter pylori

Etiological factor of some forms of gastritis (hyperacid and hypoacid) Pathogenetic relationship with duodenal ulcer, adenocarcinoma and MALT-lymphoma of the stomach CagA gene Vacuolizing toxin (vac-A) - 50-60% (switching off ion-transporting ATPases) EGF activation, HB-EGF, VEGF Alcohol dehydrogenase - acetaldehyde - lipid peroxidation - DNA damage Mucolytic enzymes

slide 15

Therapy I line - within 7-14 days: PPI: Omeprazole (Ultop, Rabeprazole, Esomeprazole) 20 mg x 2 r per day; or Lansoprazole 30 mg x 2 r daily; or Esomeprazole 40 mg x 2 r / day Clarithromycin (Fromilid) 500 mg x 2 r / day Amoxicillin (Hyconcil) 1000 mg x 2 r / day N.B.: For hypersensitivity to penicillin antibiotics, you can replace metronidazole or immediately begin quadruple therapy Efficacy of treatment regimens I line exceeds 80%. The effectiveness of the treatment is checked by a 13CO(NH)2 breath test 4 weeks after antibiotic treatment or 2 weeks after PPI.

slide 16

Therapy of the II line - quadruple therapy: Bismuth subsalicylate or subcitrate 1 tab. x 4 r / day PPI: Omeprazole (Ultop, Rabeprazole, Esomeprazole) 20 mg x 2 r per day; or Lansoprazole 30 mg x 2 r daily; or Esomeprazole 40 mg x 2 r/day Metronidazole 500 mg x 3 r/day Tetracycline hydrochloride 500 mg x 4 r/day

Slide 17

hereditary stomach cancer

A study of families with hereditary forms of stomach cancer showed that inheritance corresponds to a monogenic autosomal dominant type with high penetrance (75-95%) of the gene Morphological form - diffuse adenocarcinoma Hereditary syndromes in which stomach cancer develops with an increased frequency - familial hereditary colon polyposis Gardner and Peutz-Jeghers syndromes Lynch syndrome CDH1 is a gene associated with gastric carcinoma. It is located on chromosome 16 and encodes the E-cadherin protein, which belongs to the adhesive proteins involved in the formation of intercellular contacts. It also plays a role in signaling from the membrane to the nucleus

Slide 18

Molecular pathogenesis

p53 suppressors - inactivation by micromutations or deletions of the corresponding chromosomal locus Methylation of the promoter regions of suppressor genes leads to the phenotype of microsatellite instability, suppression of the expression of the retinoic acid receptor gene (RAR-beta), cell cycle regulators, RUNX family genes

Slide 19

Paraneoplastic syndromes

Acantosis nigricans Polymyositis with dermatomyositis Erythema annulare, bullous pemphigoid Dementia, cerebellar ataxia Venous thrombosis of extremities Multiple senile keratomas (Leuser-Trela ​​sign)

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erythema annulare

Erythema annulare is based on cutaneous vasculitis or vasomotor reaction

slide 23

bullous pemphigoid

A benign chronic skin disease, the primary element of which is a bladder that forms subepidermally without signs of acantholysis and with a negative Nikolsky symptom in all modifications. The autoallergic nature of the disease is most justified: autoantibodies to the basement membrane of the epidermis were found (more often IgG, less often IgA and other classes).

slide 24

Cerebellar ataxia-telangiectasia

Hereditary zinc-dependent immunodeficiency

Slide 25

Venous thrombosis of the extremities

There are thrombophlebitis of superficial (mainly varicose) veins and thrombophlebitis of deep veins of the lower extremities. More rare forms of thrombophlebitis include Paget's disease - Schretter (thrombosis of the axillary and subclavian veins), Mondor's disease (thrombophlebitis of the saphenous veins of the anterior chest wall), thromboangiitis obliterans (migratory thrombophlebitis of Buerger), Budd - Chiari disease (thrombosis of the hepatic veins), etc.

slide 26

Eruptive seborrheic keratosis (Leuser-Trela ​​syndrome)

It is characterized by the sudden appearance of multiple seborrheic keratosis in combination with malignant neoplasms of internal organs.

Slide 27

Slide 28

Diagnostics

Clinical picture Laboratory data X-ray examination of endoscopy with biopsy Ultrasound of peripheral and retroperitoneal lymph nodes, liver, pelvic organs, anterior abdominal wall of the umbilical region Laparoscopy Results of morphological studies

Slide 29

Classification of stomach cancer

By localization. Anatomical areas: Cardiac; Fundus of the stomach; body of the stomach; Antral and Pyloric division. +total defeat

slide 30

Stomach Cancer Clinic

Often asymptomatic Abdominal pain (60%) Weight loss (50%) Nausea and vomiting (40%) Anemia (40%) Palpation of gastric tumor (in 30%) Hematemesis and melena (25%)

Slide 31

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Syndrome of "small signs" A.I. Savitsky

Change in the patient's state of health General weakness Persistent loss of appetite "Gastric discomfort" Weight loss Anemia Loss of interest in others Mental depression

Slide 33

Primary diagnosis of stomach cancer

Clinical examination of endoscopy with multiple biopsy Histological / Cytological examination of biopsy specimens

slide 34

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Clarifying diagnostics A. Basic complex

Polypositional x-ray examination under conditions of double contrast (barium suspension and air) EGDS with biopsy from unchanged areas of the gastric mucosa outside the area of ​​the proposed resection Transabdominal ultrasound examination of the abdominal cavity, retroperitoneal space, small pelvis and cervical-supraclavicular areas X-ray of the chest in 2 projections

Slide 37

Clarifying diagnostics B. Additional methods

Computed or magnetic resonance imaging Diagnostic laparoscopy Endosonography Fluorescent diagnostics Tumor markers (REA, SA-72-4, SA-125)

Slide 38

Endosonography allows

visualize 5 layers of the unchanged stomach wall; determine the extent of the lesion, infiltration of individual layers; distinguish between a submucosal tumor of the stomach or esophagus and external pressure; assess the condition of the perigastric lymph nodes; identify invasion into neighboring organs, large vessels; with early gastric cancer, it allows with a probability of up to 80% to establish the depth of invasion within the muco-submucosal layer.

Fig.1 View of the stomach is normal

Fig.2 Submucosal cancer growth

Slide 39

Indications for diagnostic laparoscopy:

Clarifying diagnostics

subtotal / total lesion exit to serosa according to ultrasound/CT data presence of multiple enlarged regional lymph nodes according to ultrasound/CT data initial manifestations of ascites changes in the peritoneum visualized by ultrasound/CT

Contraindications:

complicated gastric cancer requiring urgent intervention (stenosis, bleeding, perforation) pronounced adhesive process in the abdominal cavity after previous operations

Slide 40

Laparoscopic fluorescent diagnostics

L Dissemination in the peritoneum is detected in 63.3%. In 16.7% of patients, dissemination was determined only in the fluorescence mode. The sensitivity of the method for gastric cancer is 72.3%, the specificity is 64%, and the overall accuracy of the method is 69%.

MNIOI them. P.A. Herzen

Slide 41

Indications for CT/MRI:

a significant discrepancy between the results of various examination methods in assessing the prevalence of the tumor process Impossibility to assess resectability according to other methods of research germination in the pancreas involvement of large vessels liver metastases suspicion of intrathoracic metastasis Planning of combined treatment

Slide 42

Sentry L/C research

slide 43

Terminology

JGCA version Early cancer - T1 N any Locally advanced cancer - T2-4 N any Russian version Early cancer - T1 N0 Locally advanced cancer - T1-4, N+ - T4 N0

Slide 44

Endoscopic classification of early gastric cancer (T1, N any, M0)

Type I - elevated (the height of the tumor is greater than the thickness of the mucous membrane) Type II - superficial IIa - elevated type IIb - flat type IIc - in-depth type III - ulcerated (ulcerative defect of the mucous membrane)

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Differential Diagnosis

Polyps and other benign tumors, incl. and leiomyomas Ulcers Lymphomas Other sarcomas, including leiomyosarcomas, GISTs Metastatic tumors of the stomach (melanoma, breast cancer, kidney cancer)

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N - Regional lymph nodes

M - Distant metastases

Remote (M) Regional (N)

Slide 53

Germination of the tumor: in the lesser and greater omentum; in the liver and diaphragm; into the pancreas; into the spleen; in the bile ducts; in the transverse colon; into the anterior abdominal wall. Lymphogenic metastasis: in regional lymph nodes; in distant lymph nodes (Virchow's metastasis, metastasis in the left axillary region), Hematogenous metastasis: in the liver; into the lungs; in the bones; into the brain. Implantation metastases: dissemination, local or total; in the pelvis (metastasis of Krukenberg, Schnitzler).

WAYS OF SPREAD OF STOMACH CANCER

Slide 54

pTNM Pathological classification

pN0 Histological analysis of the material of regional lymphadenectomy should examine at least 15 lymph nodes

G Histopathological differentiation

Gx Degree of differentiation cannot be determined G1 High degree of differentiation G2 Medium degree of differentiation G3 Low degree of differentiation G4 Undifferentiated tumor

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Treatment of stomach cancer

Surgical interventions Chemotherapy Radiation therapy Combined treatment

Slide 57

Surgery is the only potentially curable treatment for stages I-IV M0; The optimal volume of regional lymphadenectomy has not yet been established. Randomized trials known to date have not shown a benefit of D2 over D1 resection, which seems to be due to the higher complication rate after splenectomy and pancreatic tail resection (ESMO) D2 resection without spleen removal and pancreatic resection is currently recommended glands. At least 14 (optimally - 25) LU must be removed (ESMO)

Slide 58

Types of surgical interventions

Radical operations: surgical endoscopic Palliative operations

Slide 59

Endoscopic resection (ER) of the mucosa for early gastric cancer

Indications: gastric cancer structure papillary or tubular adenocarcinoma; I-IIa-b types of tumor up to 2 cm in size IIc type without ulceration up to 1 cm in size.

Frequency of lymphogenous metastases - 0% Local recurrences - 5% 5-year survival -95%

Slide 60

Surgical treatment of resectable gastric cancer stage I-IV

Gastrectomy Subtotal distal resection of the stomach Subtotal proximal resection of the stomach Extirpation of the operated stomach

Slide 61

Selecting the volume of the operation

Distal subtotal resection of the stomach is indicated for tumors of exophytic or mixed form of growth located below the conditional line connecting the point located 5 cm below the cardia along the lesser curvature and the gap between the right and left gastroepiploic arteries along the greater curvature. Proximal subtotal resection of the stomach is performed for cancer of the cardia and cardioesophageal junction. In cancer of the upper third of the stomach, it is possible to perform both proximal subtotal resection and gastrectomy. In all other cases, gastrectomy is indicated.

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When tumors of exophytic and mixed forms of growth spread to the esophagus, a deviation of 5 cm from the palpable edge of the tumor in the proximal direction is acceptable. In tumors of the endophytic form of growth, the spread of cancer cells in the proximal direction can reach 10-12 cm from the visible edge of the tumor. If the retropericardial segment of the esophagus is involved, it is advisable to perform a subtotal resection of the esophagus. Morphological control of resection margins is mandatory

Slide 64

Choice of online access

In case of gastric cancer without involving the rosette of the cardia, an upper median laparotomy to the body of the sternum and a wide diaphragmotomy according to Savinykh are performed. In case of tumors affecting the rosette of the cardia or passing to the esophagus to the level of the diaphragm, the operation is performed from the thoracolaparotomy access in the VI-VII intercostal space on the left. When the tumor spreads above the diaphragm, it is necessary to perform a separate laparotomy and thoracotomy in the V-VI intercostal space on the right.

Slide 67

Regional lymph nodes of the stomach N1

No. 1 right paracardial No. 2 left paracardial No. 3 along the lesser curvature No. 4 greater curvature No. 5 suprapyloric No. 6 subpyloric

Slide 68

Regional lymph nodes of the stomach N2

No. 7 left gastric artery No. 8 common hepatic artery No. 9 celiac trunk No. 10 hilum of the spleen No. 11 splenic artery

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Regional lymph nodes of the stomach N3

No. 12 hepatoduodenal ligament No. 13 behind the head of the pancreas No. 14 superior mesenteric vessels No. 15 - middle colic vessels No. 16 - paraaortic LUs No. 17 of the anterior surface of the pancreatic head No. 18 along the lower edge of the pancreas diaphragm

Slide 70

Regional lymph nodes of the stomach (para-aortic lymph nodes)

No. 110 Inferior paraesophageal No. 111 Supraphrenic No. 112 Posterior mediastinum

Slide 71

Volumes of lymphadenectomy

#1 right paracardial #2 left paracardial #3 along the lesser curvature #4 of the greater curvature #5 suprapyloric #6 subpyloric #7 along the left gastric artery #8 along the common hepatic artery #9 around the celiac trunk #10 hilum of the spleen #11 along the splenic artery # 12 hepatoduodenal ligament No. 19 subphrenic No. 20 of the esophageal opening of the diaphragm No. 110 lower paraesophageal No. 111 supraphrenic No. 112 lymph nodes of the posterior mediastinum No. 13 behind the head of the pancreas No. 14 along the superior mesenteric vessels No. 15 along the middle colic vessels No. 16 paraaortic No. 17 on anterior surface of the head of the pancreas No. 18 along the lower edge of the pancreas

at the transition to the esophagus

Slide 72

Splenectomy for stomach cancer

Increase in the number of purulent-septic and infectious complications (subdiaphragmatic abscesses, pancreatitis, pleurisy, pneumonia) Immunological disorders Negative effect of splenectomy on long-term results

Effects:

Slide 73

Absolute indications for splenectomy

Tumor ingrowth into the spleen Tumor ingrowth into the distal pancreas Tumor ingrowth into the splenic artery Metastases in the spleen parenchyma Tumor infiltration of the gastrosplenic ligament in the area of ​​the hilum of the spleen Inability to control hemostasis in violation of the integrity of the spleen capsule (technical splenectomy)

Slide 74

Splenectomy not indicated

localization of the tumor in the lower third of the stomach localization of the tumor along the anterior wall and lesser curvature of the stomach depth of invasion T1 – T2

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10-year results of D2 lymph node dissection versus D1 (Hartgrink et al., 2004)

Parameters* D1 D2 Locoregional recurrence 21% 19% Locoregional recurrence 37% 26% + distant metastases Distant metastases 11% 15% *All differences are not statistically significant

Slide 77

Results of D2/D3 lymphadenectomy versus D1 (D'Angelica et al., 2004)

Parameters* D1 D2/D3 Locoregional recurrence 53% 56% Peritoneal metastases 30% 27% 3. Hematogenous metastases 49% 53% *All differences are not statistically significant

Slide 78

Results of D2/D3 lymphadenectomy versus D1 (Roviello et al., 2003)

Parameters* D1 D2/D3 Locoregional recurrence 39% 27% Peritoneal metastases 16% 18% Cumulative risk of recurrence 65% 70% *All differences are not statistically significant

slide 2

Epidemiology

Gastric cancer is the second most common cause of death from malignant neoplasms. The highest incidence is recorded in Japan, China, Korea, countries of South and Central America, as well as in Eastern Europe, including the former Soviet republics. In the Russian Federation, about 40 thousand primary patients with stomach cancer are registered annually, 35 thousand die. The incidence is 28.4 per 100 thousand population. Since the middle of the 20th century, there has been a decrease in the incidence of gastric cancer worldwide due to patients with cancer of the distal stomach of the intestinal type, while the proportion of cardia cancer has been growing, and most rapidly among people under 40 years old.

slide 3

Epidemiological classification according to Lauren Intestinal type: the tumor has a structure similar to colorectal cancer, and is characterized by distinct glandular structures, consisting of well-differentiated columnar epithelium with a developed brush border. Diffuse type: the tumor is represented by poorly organized groups or single cells with a high content of mucin (cricoid) and is characterized by diffuse infiltrative growth.

slide 4

Epidemiology of stomach cancer

Peak incidence 50-60 years Men are 2-12 times more likely to get sick Localization: more often distal. However, there is a trend towards an increase in proximal and cardio-esophageal cancer, especially in Europe and America Asia - distal cancer is much more common (better treatment results and prognosis!)

slide 5

Epidemiology of gastric cancer in Europe

2006 - 159,900 new cases and 118,200 deaths, which ranks fourth and fifth in the structure of morbidity and mortality, respectively. Men get sick 1.5 times more often than women, the peak incidence occurs at the age of 60-70 years.

slide 6

Growth in standardized rates of incidence of malignant neoplasms (%%)

Slide 7

COMPARATIVE ASSESSMENT OF DIFFERENT FACTORS AFFECTING CANCER INCIDENCE

Slide 8

Johannes Fibiger 1867- 1928

Slide 9

Biography

Genus. April 23, 1867 in Silkeborg, Denmark. He studied bacteriology under the guidance of R. Koch and E. von Behring, worked together with Carl Salomonsen at the University of Copenhagen. A doctoral thesis in the bacteriology of diphtheria was completed in 1895, and in 1900 a university professor of pathology. Introduced Behring's serum for the treatment of diphtheria in Denmark and investigated the relationship between outbreaks of tuberculosis in cows and the spread of this disease in humans. Rat tuberculosis and gastric cancer with Spiroptera neoplastica (Gongylonema neoplasticum). In the 1920s, he conducted a comparative experimental study of cancer caused by coal tar, Spiroptera neoplastica and clinical manifestations. The combination of external influences with a genetic, not general, but organ predisposition to cancer. Nobel Prize in Medicine and Physiology in 1926. “For the first time, it has become possible to experimentally transform normal cells into malignant cells of cancerous tumors. Thus, it was convincingly shown not that cancer is always caused by worms, but that it can be provoked by external influences ”(W. Wernshtedt). He died in Copenhagen on January 30, 1928 from rectal cancer.

Slide 10

Etiology

A. Dietary risk factors Excessive consumption of table salt and nitrates Lack of vitamins A and C Consumption of smoked, pickled and dried foods Preservation of food without using a refrigerator Quality of drinking water B. Environmental and lifestyle factors Occupational hazards (rubber, coal production) Tobacco smoking Ionizing radiation History of gastric resection Obesity B. Infectious factors Helicobacter pylori Epstein-Barrvirus

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D. Genetic factors Blood group A (II) Pernicious anemia Familial gastric cancer Syndrome of hereditary diffuse gastric cancer (HDGC). Hereditary non-polyposis colorectal cancer Li Fraumeni syndrome (hereditary cancer syndrome) Hereditary syndromes accompanied by polyposis of the gastrointestinal tract: familial adenomatous polyposis of the colon, Gardner syndrome, Peutz-Jeghers syndrome, familial juvenile polyposis E. Precancerous diseases and changes in the gastric mucosa Adenomatous polyps of the stomach Chronic atrophic gastritis Menetrier's disease (hyperplastic gastritis) Barrett's esophagus, gastroesophageal reflux Gastric epithelial dysplasia Intestinal metaplasia

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Etiological factors of stomach cancer

Nutrition Bile reflux Helicobacter pylori Genetic disorders Risk factors - exogenous sources of nitrates and nitrites, endogenous formation of nitrates, increased salt intake, food storage, alcohol. Protective factors - antioxidants and beta-carotene.

slide 13

Dynamics of mortality from stomach cancer (total population)

Slide 14

Helicobacter pylori

Etiological factor of some forms of gastritis (hyperacid and hypoacid) Pathogenetic relationship with duodenal ulcer, adenocarcinoma and MALT-lymphoma of the stomach CagA gene Vacuolizing toxin (vac-A) - 50-60% (switching off ion-transporting ATPases) EGF activation, HB-EGF, VEGF Alcohol dehydrogenase - acetaldehyde - lipid peroxidation - DNA damage Mucolytic enzymes

slide 15

Therapy I line - within 7-14 days: PPI: Omeprazole (Ultop, Rabeprazole, Esomeprazole) 20 mg x 2 r per day; or Lansoprazole 30 mg x 2 r daily; or Esomeprazole 40 mg x 2 r / day Clarithromycin (Fromilid) 500 mg x 2 r / day Amoxicillin (Hyconcil) 1000 mg x 2 r / day N.B.: For hypersensitivity to penicillin antibiotics, you can replace metronidazole or immediately begin quadruple therapy Efficacy of treatment regimens I line exceeds 80%. The effectiveness of the treatment is checked by a 13CO(NH)2 breath test 4 weeks after antibiotic treatment or 2 weeks after PPI.

slide 16

Therapy of the II line - quadruple therapy: Bismuth subsalicylate or subcitrate 1 tab. x 4 r / day PPI: Omeprazole (Ultop, Rabeprazole, Esomeprazole) 20 mg x 2 r per day; or Lansoprazole 30 mg x 2 r daily; or Esomeprazole 40 mg x 2 r/day Metronidazole 500 mg x 3 r/day Tetracycline hydrochloride 500 mg x 4 r/day

Slide 17

hereditary stomach cancer

A study of families with hereditary forms of stomach cancer showed that inheritance corresponds to a monogenic autosomal dominant type with high penetrance (75-95%) of the gene Morphological form - diffuse adenocarcinoma Hereditary syndromes in which stomach cancer develops with an increased frequency - familial hereditary colon polyposis Gardner and Peutz-Jeghers syndromes Lynch syndrome CDH1 is a gene associated with gastric carcinoma. It is located on chromosome 16 and encodes the E-cadherin protein, which belongs to the adhesive proteins involved in the formation of intercellular contacts. It also plays a role in signaling from the membrane to the nucleus

Slide 18

Molecular pathogenesis

p53 suppressors - inactivation by micromutations or deletions of the corresponding chromosomal locus Methylation of the promoter regions of suppressor genes leads to the phenotype of microsatellite instability, suppression of the expression of the retinoic acid receptor (RAR-beta) gene, cell cycle regulators, genes of the RUNX family

Slide 19

Paraneoplastic syndromes

Acantosis nigricans Polymyositis with dermatomyositis Erythema annulare, bullous pemphigoid Dementia, cerebellar ataxia Venous thrombosis of extremities Multiple senile keratomas (Leuser-Trela ​​sign)

Slide 20

Blackening acanthosis

slide 21

Polymyositis with dermatomyositis

slide 22

erythema annulare

Erythema annulare is based on cutaneous vasculitis or vasomotor reaction

slide 23

bullous pemphigoid

A benign chronic skin disease, the primary element of which is a bladder that forms subepidermally without signs of acantholysis and with a negative Nikolsky symptom in all modifications. The autoallergic nature of the disease is most justified: autoantibodies to the basement membrane of the epidermis were found (more often IgG, less often IgA and other classes).

slide 24

Cerebellar ataxia-telangiectasia

Hereditary zinc-dependent immunodeficiency

Slide 25

Venous thrombosis of the extremities

There are thrombophlebitis of superficial (mainly varicose) veins and thrombophlebitis of deep veins of the lower extremities. More rare forms of thrombophlebitis include Paget's disease - Schretter (thrombosis of the axillary and subclavian veins), Mondor's disease (thrombophlebitis of the saphenous veins of the anterior chest wall), thromboangiitis obliterans (migratory thrombophlebitis of Buerger), Budd - Chiari disease (thrombosis of the hepatic veins), etc.

slide 26

Eruptive seborrheic keratosis (Leuser-Trela ​​syndrome)

It is characterized by the sudden appearance of multiple seborrheic keratosis in combination with malignant neoplasms of internal organs.

Slide 27

HISTOLOGICAL CLASSIFICATION OF GASTRIC TUMORS (WHO, 2000)

Slide 28

Diagnostics

Clinical picture Laboratory data X-ray examination of endoscopy with biopsy Ultrasound of peripheral and retroperitoneal lymph nodes, liver, pelvic organs, anterior abdominal wall of the umbilical region Laparoscopy Results of morphological studies

Slide 29

Classification of stomach cancer

By localization. Anatomical areas: Cardiac; Fundus of the stomach; body of the stomach; Antral and Pyloric division. +total defeat

slide 30

Stomach Cancer Clinic

Often asymptomatic Abdominal pain (60%) Weight loss (50%) Nausea and vomiting (40%) Anemia (40%) Palpation of gastric tumor (in 30%) Hematemesis and melena (25%)

Slide 31

MAIN SYMPTOMS OF GASTRIC CANCER 18,365 p. (Wanebo et al., 1993)

slide 32

Syndrome of "small signs" A.I. Savitsky

Change in the patient's state of health General weakness Persistent loss of appetite "Gastric discomfort" Weight loss Anemia Loss of interest in others Mental depression

Slide 33

Primary diagnosis of gastric cancer Clinical examination of endoscopy with multiple biopsy Histological / cytological examination of biopsy specimens

slide 34

The role of endoscopy 1982 - 1 biopsy - 70%; 7 biopsies - 98% (Graham D.) 2013 – modern endoscopy technologies high resolution endoscopy (HRE) magnifying endoscopy (ZOOM) (x 80 - 150) narrow band endoscopy (NBI) fluorescent endoscopy chromoendoscopy

Slide 35

Narrow band endoscopy (NBI endoscopy)

slide 36

Clarifying diagnosis A. Basic complex Polypositional x-ray examination under conditions of double contrast (barium suspension and air) EGDS with biopsy from unchanged areas of the gastric mucosa outside the area of ​​the proposed resection Transabdominal ultrasound examination of the abdominal cavity, retroperitoneal space, small pelvis and cervical-supraclavicular zones. X-ray of the chest in 2 projections

Slide 37

Clarifying diagnostics C. Additional methods Computed or magnetic resonance imaging Diagnostic laparoscopy Endosonography Fluorescent diagnostics Tumor markers (REA, SA-72-4, SA-125)

Slide 38

Endosonography allows visualization of 5 layers of the unchanged stomach wall; determine the extent of the lesion, infiltration of individual layers; distinguish between a submucosal tumor of the stomach or esophagus and external pressure; assess the condition of the perigastric lymph nodes; identify invasion into neighboring organs, large vessels; with early gastric cancer, it allows with a probability of up to 80% to establish the depth of invasion within the muco-submucosal layer. Fig. 1 Normal view of the stomach Fig. 2 Submucosal cancer growth

Slide 39

Indications for diagnostic laparoscopy: Clarifying diagnosis Subtotal / total lesion Exit to serosa according to ultrasound/CT data Presence of multiple enlarged regional lymph nodes according to ultrasound/CT data Initial manifestations of ascites Changes in the peritoneum visualized by ultrasound/CT Contraindications: complicated gastric cancer requiring urgent intervention (stenosis , bleeding, perforation) pronounced adhesive process in the abdominal cavity after previous operations

Slide 40

Laparoscopic fluorescent diagnostics L Dissemination in the peritoneum is detected in 63.3%. In 16.7% of patients, dissemination was determined only in the fluorescence mode. The sensitivity of the method for gastric cancer is 72.3%, the specificity is 64%, and the overall accuracy of the method is 69%. MNIOI them. P.A. Herzen

Slide 41

Indications for CT/MRI: a significant discrepancy between the results of various examination methods in assessing the prevalence of the tumor process Impossibility to assess resectability according to other methods of examination Sprouting into the pancreas Involvement of large vessels Liver metastases Suspicion of intrathoracic metastasis Combined treatment planning Clarifying diagnosis

Slide 42

Study of sentinel L/C 1 2 3 4

slide 43

Terminology

JGCA version Early cancer - T1 N any Locally advanced cancer - T2-4 N any Russian version Early cancer - T1 N0 Locally advanced cancer - T1-4, N+ - T4 N0

Slide 44

Endoscopic classification of early gastric cancer (T1, N any, M0) Type I - elevated (tumor height greater than the thickness of the mucous membrane) Type II - superficial IIa - elevated type IIb - flat type IIc - deep type III - ulcerated (ulcerative defect of the mucous membrane)

Slide 45

Borrman classification of advanced gastric cancer

Slide 46

Differential Diagnosis

Polyps and other benign tumors, incl. and leiomyomas Ulcers Lymphomas Other sarcomas, including leiomyosarcomas, GISTs Metastatic tumors of the stomach (melanoma, breast cancer, kidney cancer)

Slide 47

STOMACH (ICD-O C16)

Slide 48

T - primary tumor

Slide 49

Slide 50

NOTES

Slide 51

Regional lymph nodes

Slide 52

N - Regional lymph nodes M - Distant metastases Distant (M) Regional (N) Distant (M) Regional (N)

Slide 53

Germination of the tumor: in the lesser and greater omentum; in the liver and diaphragm; into the pancreas; into the spleen; in the bile ducts; in the transverse colon; into the anterior abdominal wall. Lymphogenic metastasis: in regional lymph nodes; in distant lymph nodes (Virchow's metastasis, metastasis in the left axillary region), Hematogenous metastasis: in the liver; into the lungs; in the bones; into the brain. Implantation metastases: dissemination, local or total; in the pelvis (metastasis of Krukenberg, Schnitzler). WAYS OF SPREAD OF STOMACH CANCER

Slide 54

pTNM Pathological classification pT, pN and pM categories correspond to T, N and M categories. pN0 Histological analysis of regional lymphadenectomy material should include at least 15 lymph nodes G Histopathological differentiation Gx Degree of differentiation cannot be established G1 High degree of differentiation G2 Medium degree of differentiation G3 Low degree of differentiation G4 Undifferentiated tumor

Slide 55

Grouping by stages

Slide 56

Treatment of stomach cancer

Surgical interventions Chemotherapy Radiation therapy Combined treatment

Slide 57

Surgery is the only potentially curable treatment for stages I-IV M0; The optimal volume of regional lymphadenectomy has not yet been established. Randomized trials known to date have not shown a benefit of D2 over D1 resection, which seems to be due to the higher complication rate after splenectomy and pancreatic tail resection (ESMO) D2 resection without spleen removal and pancreatic resection is currently recommended glands. At least 14 (optimally - 25) LU must be removed (ESMO)

Slide 58

Types of surgical interventions

Radical operations: surgical endoscopic Palliative operations

Slide 59

Endoscopic resection (ER) of the mucosa in early gastric cancer Indications: gastric cancer structure of papillary or tubular adenocarcinoma; I-IIa-b types of tumor up to 2 cm in size IIc type without ulceration up to 1 cm in size. I IIa IIb IIc Frequency of lymphogenous metastases - 0% Local recurrences - 5% 5-year survival rate -95%

Slide 60

Surgical treatment of resectable gastric cancer stage I-IV Scope of operation Gastrectomy Subtotal distal resection of the stomach Subtotal proximal resection of the stomach Extirpation of the operated stomach

Slide 61

Selection of the scope of the operation Distal subtotal resection of the stomach is indicated for tumors of exophytic or mixed form of growth located below the conditional line connecting the point located 5 cm below the cardia along the lesser curvature and the gap between the right and left gastroepiploic arteries along the greater curvature. Proximal subtotal resection of the stomach is performed for cancer of the cardia and cardioesophageal junction. In cancer of the upper third of the stomach, it is possible to perform both proximal subtotal resection and gastrectomy. In all other cases, gastrectomy is indicated.

Slide 62

Choice of the scope of the operation Additional criteria influencing the choice of the scope of the operation: age, comorbidities, underlying diseases of the stomach, prognosis, other factors (the course of anesthesia, anatomical features, subjective, etc.)

Slide 63

Choosing the scope of the operation When tumors of exophytic and mixed forms of growth spread to the esophagus, a deviation of 5 cm from the palpable edge of the tumor in the proximal direction is acceptable. In tumors of the endophytic form of growth, the spread of cancer cells in the proximal direction can reach 10-12 cm from the visible edge of the tumor. If the retropericardial segment of the esophagus is involved, it is advisable to perform a subtotal resection of the esophagus. Morphological control of resection margins is mandatory

Slide 64

Choice of operative approach In case of gastric cancer without involving the rosette of the cardia, an upper median laparotomy to the body of the sternum and a wide diaphragmotomy according to Savinykh are performed. In case of tumors affecting the rosette of the cardia or passing to the esophagus to the level of the diaphragm, the operation is performed from the thoracolaparotomy access in the VI-VII intercostal space on the left. When the tumor spreads above the diaphragm, it is necessary to perform a separate laparotomy and thoracotomy in the V-VI intercostal space on the right.

Slide 65

Slide 66

Slide 67

Regional lymph nodes of the stomach N1 No. 1 right paracardial No. 2 left paracardial No. 3 along the lesser curvature No. 4 greater curvature No. 5 suprapyloric No. 6 subpyloric

Slide 68

Regional lymph nodes of the stomach N2 No. 7 left gastric artery No. 8 common hepatic artery No. 9 celiac trunk No. 10 hilum of the spleen No. 11 splenic artery

Slide 69

Regional lymph nodes of the stomach N3 No. 12 of the hepatoduodenal ligament No. 13 behind the head of the pancreas No. 14 of the superior mesenteric vessels No. 15 - middle colic vessels No. 16 - paraaortic LU No. 17 of the anterior surface of the head of the pancreas No. 18 along the lower edge of the pancreas No. 19 subphrenic LU No. 20 of the esophageal opening of the diaphragm

Slide 70

Regional lymph nodes of the stomach (paraortal lymph nodes) No. 110 lower paraesophageal No. 111 supraphrenic No. 112 of the posterior mediastinum

Slide 71

D1 D2 Volumes of lymphadenectomy D3 No. 1 right paracardial No. 2 left paracardial No. 3 along the lesser curvature No. 4 greater curvature no. 11 along the splenic artery #12 hepatoduodenal ligament #19 subphrenic #20 hiatal opening #110 inferior paraesophageal #111 suprapphrenic #112 posterior mediastinal lymph nodes #13 behind the head of the pancreas #14 along the superior mesenteric vessels #15 along the middle colic vessels # 16 para-aortic No. 17 on the anterior surface of the head of the pancreas No. 18 along the lower edge of the pancreas at the transition to the esophagus

Slide 72

Splenectomy for gastric cancer Increase in the number of purulent-septic and infectious complications (subdiaphragmatic abscesses, pancreatitis, pleurisy, pneumonia) Immunological disorders Negative effect of splenectomy on long-term results Consequences:

Slide 73

Absolute indications for splenectomy Tumor ingrowth into the spleen Tumor ingrowth into the distal pancreas Tumor ingrowth into the splenic artery Metastases in the spleen parenchyma Tumor infiltration of the gastrosplenic ligament in the area of ​​the hilum of the spleen Inability to control hemostasis in violation of the integrity of the spleen capsule (technical splenectomy)

Slide 74

Splenectomy is not indicated Localization of the tumor in the lower third of the stomach Localization of the tumor along the anterior wall and lesser curvature of the stomach Depth of invasion T1 – T2

Slide 75

Classification of surgical interventions

Slide 76

10-year results of D2 lymph node dissection compared to D1 (Hartgrink et al., 2004)

Parameters* D1D2 Locoregional recurrence 21% 19% Locoregional recurrence 37% 26% + distant metastases Distant metastases 11% 15% *All differences are not statistically significant

Slide 77

Results of D2/D3 lymphadenectomy versus D1 (D'Angelica et al., 2004)

Parameters* D1 D2/D3 Locoregional recurrence 53% 56% Peritoneal metastases 30% 27% 3. Hematogenous metastases 49% 53% *All differences are not statistically significant

Slide 78

Results of D2/D3 lymphadenectomy versus D1 (Roviello et al., 2003)

Parameters* D1 D2/D3 Locoregional recurrence 39% 27% Peritoneal metastases 16% 18% Cumulative risk of recurrence 65% 70% *All differences are not statistically significant

Slide 79

Combined surgeries for stomach cancer

A methodology has been developed for advanced combined operations for locally advanced gastric cancer by the type of upper left abdominal evisceration with resection of the transverse colon, pancreas, diaphragm, left lobe of the liver, adrenal gland, kidney

(Russian Cancer Research Center named after N.N. Blokhin RAMS) years

Slide 83

FUNCTIONAL ASPECTS OF THE OPERATION Options for plasty after gastrectomy

Loop plasty Roux-en-Y plasty Loop tank

Slide 84

FUNCTIONAL ASPECTS OF THE OPERATION

Options for plastic surgery after proximal resection of the stomach After proximal resection of the stomach, the methods of esophago-gastrostomy and interposition of a loop of the large or small intestine are used. The weak point of esophagogastrostomy is the high incidence of reflux esophagitis. From a physiological point of view, the interposition method is the best, and if the length of the interposed intestine is 30 cm or more, the risk of reflux esophagitis is minimal.

Slide 85

Significance of reconstruction

Improving the quality of life of patients by increasing the amount of food intake and reducing the frequency of meals; Stabilization of body weight indicators; Prevention of esophageal reflux.

Slide 86

Reconstruction methods with the inclusion of the duodenum 12

Hunt-Lawrence-Rodino

Slide 87

Resectable gastric cancer stage IV 1. Cytoreductive operations are indicated: in case of locally advanced gastric cancer stage IV (T3N3), solitary and single isolated liver metastases of limited dissemination in the peritoneum with the possibility of performing complete cytoreduction R0. 2. After the operation, it is advisable to conduct polychemotherapy. 3. With massive carcinomatosis, multiple distant metastases, impossibility of complete cytoreduction R0, the results of surgical treatment are unsatisfactory. Operations are expedient only with a palliative purpose in patients with a complicated course of cancer.

Slide 88

Chemotherapy

Neoadjuvant Adjuvant Intraperitoneal a) Intraoperative b) Adjuvant Palliative

Slide 89

Adjuvant therapy Results of surgical treatment remain unsatisfactory Adjuvant radiation therapy, while reducing the rate of local recurrences, does not improve survival Adjuvant chemotherapy after radical surgery only slightly improves long-term results, as confirmed by numerous studies Hermans et al, 1993, 11 studies, n=2096 Earle and Maroun, 1999, 13 studies, n=1990

Slide 90

Adjuvant therapy In 2007, the results of a Japanese randomized trial were published that studied the effectiveness of adjuvant monochemotherapy with a new oral chemotherapy drug from the fluoropyrimidine group, S-1. The drug was administered orally at 80 mg/m2 per day for a year after radical surgery for stage II-III gastric cancer. The duration of one course was 4 weeks with a 2-week break. An analysis of long-term results showed a significant increase in the 3-year survival of patients who received adjuvant chemotherapy with S-1 from 70.1% to 80.1%.99

Slide 91

Perioperative chemotherapy

MAGIC Randomized Trial Treatment included 3 cycles of neoadjuvant ECF chemotherapy (epirubicin, cisplatin, 5-FU) followed by surgery and 3 more cycles of similar chemotherapy. The study demonstrated a significant increase in 5-year survival from 23% to 36% in the combination treatment group. Cunningham D, Allum WH, Stenning SP, et al. Perioperative chemotherapy versus surgery alone for resectable gastroesophageal cancer. N Engl J Med 2006;355:11-20

Slide 92

Intergroup randomized study (INT-0116). 603 patients with resectable gastric cancer surgery + adjuvant therapy or surgery alone Adjuvant therapy regimen: 1 course of 5-FU + leucovorin radiotherapy 45 Gy (25 days) + 5FU / leucovorin on days 1, 4, 23 and 25 of radiation 2 courses of chemotherapy 5-FU / Leucovorin Adjuvant Chemoradiation Therapy

Slide 93

Adjuvant chemoradiotherapy Efficacy: disease-free 3-year survival 49% vs 32% 3-year survival 52% vs 41% median survival 35 vs 28 months A critical review of the INT-0166 trial showed that the extent of surgical treatment was inadequate in most patients. Thus, extended D2 lymphadenectomy was performed only in 10% of patients, standard D1 lymphadenectomy was performed in 36%, and in 54% of patients, the volume of lymphadenectomy was characterized as D0. Against this background, the frequency of local recurrences in the group of only surgical treatment reached 64%, which is significantly worse than the results of gastric cancer treatment in Europe and Japan. In the group of patients who underwent D2 lymphadenectomy, there was no significant increase in survival as a result of complex treatment.

Slide 94

Adjuvant chemoradiotherapy

The study included 990 patients. Main group (544) - D2 operation + CRT (scheme similar to INT 0116), control - only D2 operation (446) Results: Kim S., Lim DH., Lee J., et al. Int J Radiat Oncol Biol Phys. 2005 Dec 1;63(5):1279-85

Slide 95

Intra-abdominal hyperthermic chemotherapy (HIPEC) for gastric cancer Kimet al. 2001 (n=103) Prevention of carcinomatosis in gastric cancer with serosa invasion 5-year survival rate for tumors with serosa invasion (excluding stage IV) increased from 44.4% to 58.5%, and in stage IIIB - from 25% to 41.7%. T3-T4 IIIB HIPEC HIPEC control control

Slide 96

Palliative chemotherapy for gastric cancer

Monochemotherapy rarely leads to remission Polychemotherapy is more effective, but increases the toxicity and cost of treatment Chemotherapy of gastric cancer in mono mode with 5-fluorouracil

View all slides

Peoples' Friendship University of Russia
Department of Surgical Diseases
Presentation prepared by: Anastasia Kuznetsova
student of the 3rd year of the medical faculty of group MS-301

Stomach cancer, what is it?

Gastric cancer is one of the most common malignant tumors in humans. By
incidence statistics, gastric cancer ranks first in many countries, in particular,
in the Scandinavian countries, in Japan, in Ukraine, in Russia and other CIS countries.
At the same time, in the USA, France, England, Spain, Israel, in the last twenty years there has been
reduction in the incidence of stomach cancer. Many experts believe that this happened
by improving food storage conditions with widespread use
refrigeration units, which reduced the need for preservatives. In these countries
decreased consumption of salt, salty and smoked foods, increased consumption of
dairy products, organic, fresh vegetables and fruits.
The high incidence of stomach cancer in the above countries, with the exception of Japan,
according to many authors, due to the consumption of foods containing
nitrites. Nitrosamines are formed from nitrites by transformation in the stomach.
Currently, gastric cancer began to be detected more often at a young age, in age groups.
groups of 40-50 years. The largest group of gastric cancers are adenocarcinomas and
undifferentiated cancers. Cancers usually develop as a result of chronic
inflammatory diseases of the stomach.
It has now been proven that in an absolutely healthy stomach, cancer is almost non-existent.
arises. It is preceded by a precancerous condition. Most often this happens when
chronic gastritis with low acidity, ulcers and polyps in the stomach. On average from
precancer to cancer takes 10 to 20 years.

The structure of the stomach

Histological structure of the stomach

Precancerous conditions

chronic atrophic gastritis
chronic stomach ulcer
adenomatous polyps
intestinal metaplasia of the gastric mucosa
severe dysplasia of the gastric mucosa
Menetrier's disease (growth of the mucous membrane).
anemia caused by vitamin B12 deficiency.
This vitamin plays an important role in the formation of cells
body, especially the epithelium of the gastrointestinal tract.

Precancers

The first signs of stomach cancer

First, stomach cancer has signs,
common to cancer.
Chronic fatigue.
Fast fatiguability.
Unexplained weight loss.

Small signs of stomach cancer

Secondly, the presence of early stomach cancer can
signal a complex of symptoms, or the so-called
syndrome of small signs.
Discomfort in the stomach after eating: bloating,
a feeling of fullness.
Frequent nausea, vomiting, slight salivation.
Pain in the epigastrium: aching, pulling, dull. May occur
periodically, often appear after eating.
Loss of appetite not motivated by other factors.
Frequent heartburn, difficulty swallowing food and liquids (if
the tumor originated in the upper part of the stomach).
Vomiting of stagnant contents (eaten a day or two ago);
vomiting "coffee grounds" or with blood,
loose black stools - signs of bleeding in the stomach,
requiring an urgent call for an ambulance.

Symptoms of stomach cancer largely depend on the location of the tumor.

With cancer of the cardiac region (the initial part of the stomach)
symptoms of dysphagia (salivation, difficulty
during the passage of coarse food). Dysphagia increases as
progression of the disease and narrowing of the lumen of the esophagus. On this background
there is regurgitation of food, dull pain or a feeling of pressure behind
sternum, in the region of the heart or in the interscapular space. Cause
these symptoms may be stagnation of food in the esophagus, expansion of it.
With localization of cancer in the antrum (the final part of the stomach)
relatively early there is a feeling of heaviness in the upper abdomen,
vomiting of food eaten the day before, an unpleasant rotten smell of vomit.
For cancer of the body of the stomach (middle part of the stomach),
even with a significant size of the tumor, local symptoms of the disease
are absent for a long time, general symptoms predominate - weakness,
anemia, weight loss, etc.

3. Painful form of stomach cancer.
Often worried about pain in the upper abdomen, which can
give to the lower back and be associated with food intake.
Pain often continues for a long period
time, sometimes all day, may be aggravated by movement.
With stomach cancer, pain is not regular. They are
do not subside after eating, there are no "hungry" pains or their
seasonality. In some cases, with common forms
stomach cancer pain can be quite intense
character. When the tumor grows into the pancreas
or even deeper patients may complain of back pain.
Such patients are usually treated for sciatica,
neuralgia.

Histogenesis of stomach cancer

The question is debatable. There are several hypotheses about the sources
occurrence of various histological types of cancer
stomach.
For example, Professor V.V. Serov believes that stomach cancer
arises from a single source - cambial elements, or
progenitor cells in the foci of dysplasia and outside them.
Some European authors suggest that
adenocarcinoma of the stomach arises from the intestinal epithelium, and
undifferentiated cancers - from the gastric.
Head Professor I.V. Vasilenko, head of the DonGMU department, believes that
source of adenocarcinomas are
proliferating cells of the pit-covering epithelium
mucous membrane of the stomach, and from the epithelium of the necks of the glands
undifferentiated cancers.

The nature of metastasis

Gastric cancer is prone to early
the occurrence of a large number of metastases.

Metastasis of stomach cancer is carried out - lymphogenous, hematogenous and implantation (contact) way.

Of particular importance are lymphogenous metastases in regional lymph nodes.
nodes located along the lesser and greater curvature of the stomach, as well as in
lymph nodes of the greater and lesser omentum. They appear first and determine
volume and nature of the surgical intervention. to distant lymphogenous
metastases include metastases in the lymph nodes of the gate of the liver (periportal),
parapancreatic and paraaortic. To the most important in terms of localization, which has
diagnostic value, include retrograde lymphogenous metastases:
- "Virchow metastases" - in the supraclavicular lymph nodes (often in the left);
- "Krukenberg ovarian cancer" - in both ovaries;
- "Schnitzler metastases" - in the lymph nodes of pararectal tissue.
In addition, lymphogenous metastases to the pleura, lungs, and peritoneum are possible.
Hematogenous metastases in the form of multiple nodes are found in the liver, in
lungs, pancreas, bones, kidneys and adrenal glands.
Implantation metastases are manifested in the form of multiple different
the size of the tumor nodes in the parietal and visceral peritoneum, which
accompanied by fibrinous-hemorrhagic exudate.

Localization

Most often, stomach cancer occurs:
in the pyloric region
then on the lesser curvature,
in the cardia, on the greater curvature,
less often - on the front and back wall,
very rarely - in the bottom area.

The degree of spread of the tumor of the cardia.

T1 - the tumor does not extend beyond the cardia;
T2 - the tumor occupies the cardiac region;
TK - tumor of the cardia extends to the esophagus and
body of the stomach.

Stomach cancer stages

Cancer detection from one stage to
the other increases, and at the same time
reduced life expectancy
patient, the likelihood of recovery.
Four stages can be identified
disease progression:

Zero stage.

Only the gastric mucosa is affected.
Cancer treatment in this case is possible without
strip operation, with
using endoscopic techniques and
the use of anesthesia.
In this case, the treatment of stomach cancer has
the most favorable prognosis - 90% of cases
convalescence.

1 stage.

The tumor penetrates deeper into the mucosa
shell, and also creates metastases in
lymph nodes around the stomach.
Survival with cancer treatment at this stage
is 60-80%, but such cancer is detected
rarely.

2 stage.

The tumor does not affect only the muscle
stomach tissue, there are metastases in
lymph nodes.
Five year survival at
diagnosing the disease at stage 2 - 56%.

3 stage.

Cancer penetrates entirely into the walls of the stomach,
lymph nodes are affected.
Stomach cancer of the 3rd degree is detected
quite often (1 case out of seven), but
five-year survival in this case -
15–38 %.

4 stage.

A cancerous tumor penetrates not only into the stomach,
but also gives metastases to other organs:
pancreas, large blood vessels,
peritoneum, liver, ovaries and even lungs.
Cancer in this form is diagnosed in 80% of patients.
Only in 5% of cases, the medical prognosis
the life expectancy of the patient exceeds 5 years.

Stomach cancer is classified

1. Polyposis cancer.
2. Ulcerative (saucer-shaped) cancer
stomach.
3. Infiltrative and ulcerative tumor.
4. Scirrhous gastric cancer with a diffuse infiltrative type of growth.

For the polyposis form of the disease, stomach cancer is characterized by:

1. Difficult visual differentiation from benign polyps with
no signs of germination of the entire wall.
2. Loss of diameter reduction that is characteristic of non-cancerous polyps
base before attaching to the mucosa. The isthmus, on the contrary, thickens along
diameter, acquiring the appearance of an elevated roller.
3. Loose surface of the formation corroded by erosions and ulcers with foci
bumpy elevations.
4. When taking material for histological examination, crushing is observed
tissue at the slightest effort, followed by bleeding.
The results of the biopsy confirm the diagnosis of cancer. To do this, the collection of material from
using tweezers is made from several suspicious areas and on
border with visually unchanged tissue. Because in the areas of tumor decay,
often, apart from necrotic tissue and inflammatory blood cells, nothing
fails to identify. Statistically, when taking only one piece from the tumor
the diagnosis of gastric cancer can be made only in 70% of cases, while when taking
eight and from different parts of the tumor, the diagnosis increases to 96-99%.
Increasing more than the number of pieces taken is essential for
is no longer diagnostic. Experienced endoscopists also take a few pieces from
one place, to study the depth of germination of cancer.

Ulcerative (saucer-shaped) stomach cancer

Occurs in 10-40% of diagnosed malignant neoplasias
stomach. Most often located in the anterior wall of the antrum,
less often - in other walls of the same department.
Outwardly, it resembles the appearance of a small saucer up to 10 cm in diameter, with
depressed bottom and elevated above the common surface of the mucosa
bumpy edges, without a clear observance of a certain height, with
comb-like influxes along the periphery. The bottom of the ulcer is also uneven. It
may be covered with thin fibrous or lamellar
overlays, from gray-yellow to red-brown or even black
colors. The mucosa along the edges of the ulcer-cancer is not thickened, but also active
contraction of the muscles of the stomach is also not determined here. When taking
biopsy, denseness of the tumor tissue is felt, blood in response
released in small quantities.

Infiltrative-ulcerative cancer of the stomach

Diagnosed in 45-60% of cases. Detect only on the lesser curvature
any part of the stomach. Defined as slightly depressed rounded
mucosal defect, with uneven edges and a diameter rarely exceeding 6
see. The surface of the defect is uneven, dull, cloudy. uplift
the edges of the ulcer along the periphery are rarely observed and their height is insignificant, without
full coverage of the entire perimeter, often without a clear boundary of the transition to
surrounding mucosa. Folding of the mucosa, preserved around the ulcer,
interrupted in it and restored further throughout. However,
mucosal folds near the tumor are wider, not so high, not
deform when pressed and do not straighten when applied
air. Muscular peristalsis of the stomach wall in their projection also does not
observed. Taking a biopsy leaves behind a weak
bleeding.

Scirrhous gastric cancer with diffuse-infiltrative type of growth

This type of malignant growth of stomach cancer is detected in 10-30% of cases. Diagnosing it
with the help of endoscopic research methods is difficult and is built, for the most part,
on indirect evidence: thickening of the stomach wall with stiff, somewhat
reduced folding frequency of the mucosa with relative enlightenment in relation to
surrounding areas. If the tumor begins to grow into the mucous membrane, then its diagnosis
facilitated, since the appearance of the affected wall and its folding become
characteristic of malignant diseases:
a bulging contour of the affected area appears with the absence of peristaltic
movements,
folds "freeze" and do not respond to various influences,
the gastric mucosa in these areas becomes gray-ashy.
Redness of the affected areas of the mucosa, with possible soaking in blood,
erosion and even ulceration - can be observed with the addition of a secondary
infections. In a similar situation, diffuse-infiltrative gastric cancer for an endoscopist
becomes difficult to distinguish from superficial forms of gastritis, erosions and ulcers of non-tumor
etiology. It should not be forgotten that with appropriate treatment of the phenomenon of acute
inflammation may resolve with continued spread of the tumor to other
walls, causing a decrease in elasticity and leading to a narrowing of the lumen of the stomach. And even
the slightest movement of the gastroscope, with minimal air injection, is already beginning
cause severe pain in the patient. This again speaks of the diagnostic
the importance of biopsy of the stomach in any acute changes, as well as after them
cure.

Gastric cancer and diagnosis

The main study for gastric cancer is FGDS, which gives
the possibility of a detailed examination of the mucous membrane of the esophagus,
duodenum and stomach, and detection of a tumor, determination of its
borders.
X-ray of the stomach - effective in infiltrative forms of cancer.
Allows you to assess the functionality of the body, gives
the possibility of suspecting gastric cancer or the onset of recurrence of the tumor. Such
diagnostic method is necessary in order to carry out effective treatment in the future
stomach cancer.
Endoscopic ultrasonography - allows you to accurately examine the condition
all layers of the stomach and in 80-90% of cases accurately determine the depth of the tumor.
The direction of magnifying endoscopy occupies one of the leading places in
clarifying diagnosis of gastric pathology, as it allows to identify
minimal disturbances in the typical architectonics of the mucous membrane and to distinguish between
areas of intestinal metaplasia and dysplasia or the presence of neoplastic changes.
Improving endoscopic examination is in the direction of introducing
narrow-spectrum (NBI-endoscopy). These are high-tech methods that
allow early detection of gastric cancer, and
promote identification of the centers of a tumor against hron. stomach diseases.

Gastric cancer and diagnosis

Optical coherence tomography - designed to determine the depth
invasion into the wall of the stomach, esophagus or other hollow organ. This equipment
a new generation allows you to determine in detail the thickness of the affected tissue,
it is possible to recognize the germination of the tumor in the submucosal and muscle layers
stomach. Under the control of optical coherence tomography, tissue sampling is carried out
lymph nodes in the surrounding area.
Diagnostic laparoscopy is a surgical procedure that
performed under intravenous anesthesia by puncture in the abdominal wall
camera to examine the abdominal organs. This research is applied
in unclear cases, to detect germination in surrounding organs
neoplasms, metastases in the peritoneum and for taking a biopsy. This method is sometimes
essential for effective treatment of gastric cancer.
Gastric cancer and blood tests for tumor markers - proteins that
produced by the tumor and not present in the healthy body. With the aim of
CEA, Ca 19.9 and Ca 72.4 are used for cancer detection. However, they all have
low diagnostic value. They have found their use in patients for
metastasis detection.

Treatment of stomach cancer

The treatment of cancer is different from the treatment of other organs.
If with carcinomas in other organs, surgery
is done only when the usual
therapy, then the opposite is true for stomach cancer.
Only surgery can save
sick. This is explained by the fact that the signs of cancer
unstable and may not appear for months, eventually
the patient comes already at the moment when it began
phase of stenosis and metastasis.

Treatment Methods

Chemotherapy, despite its possibilities, rarely
helps to stop the development of metastases and destroy cancer
cells in adjacent organs.
Radiation therapy, which is used for most cancers
formations, in cases with the stomach is not carried out.
Medical treatment will no longer bring any
result, so the only way is the surgical path.
If the carcinoma is small, then do
resection of the stomach, removing most of it.
But in many cases, the stomach has to be removed completely,
at the same time, all affected lymph nodes are removed. During
operations, the esophagus is sewn directly to the intestine.

Surgical treatment of stomach cancer

In addition to removing the tumor of the stomach, removal of lymph nodes and fatty tissue is performed.
fiber. Lymph node dissection makes it possible to significantly increase the 5-year
survival and reduce the number of relapses. All operations are performed
minimally invasive using laparoscopic techniques. Subtal resection
is done with a small tumor, which is located at the exit from the stomach, and
approximately 4/5 of the stomach is removed. The remaining cases are the removal of the stomach and
all areas in which lymph nodes with metastases are located, while
the esophagus is sutured to the small intestine.
Treatment with surgical radical intervention
subtotal proximal resection of the stomach;
gastrectomy;
subtotal distal resection of the stomach.
Subtotal distal resection
During this operation, ¾ of the distal stomach with a ligamentous apparatus is removed and
lymph nodes. The entire lesser curvature is removed.

Subtotal proximal resection of the stomach
This operation involves the removal of the entire lesser curvature of the stomach with
paraesophageal lymph nodes and lesser omentum, as well as
part of the greater omentum.
Treatment of gastric cancer with gastrectomy
With it, the complete removal of the stomach with the ligamentous apparatus is carried out,
omentums and all areas of metastasis.
If stomach cancer has spread to neighboring organs, do
extended combined resections and gastrectomy, and together
with complete or partial removal of the stomach, a part of the neighboring
organ.

Other treatments

Palliative surgery for gastric cancer
There are two types of palliative surgery:
The operation is aimed at improving the general condition and nutrition of the patient, not
eliminating stomach cancer. Such operations are considered a bypass anastomosis between
stomach and small intestine - gastroenteroanastomosis, gastro- and jejunostomy.
With such an operation, the primary focus or cancer metastasis is removed
stomach. These operations include palliative resections, removal
metastasis and palliative gastrectomy.
Gastroenterostomy - treatment of stomach cancer by creating an anastomosis between
jejunum and stomach.
Gastrostomy - is the introduction of the probe into the stomach through the abdominal
wall to feed the patient.
Enterostomy - performed to create patency of the digestive
a path if there is no possibility of imposing of a gastromtomy, and also for food
sick.

relapse

Even a complete cure for stomach cancer is not
always has a positive outlook:
frequent relapses that are far
can not always be eliminated by repeated
operations.

Rules for the prevention of stomach cancer:

Identification of precancerous conditions and regular medical examination.
Diet. Reduce the consumption of fatty, salty, smoked and fried foods, spicy and
spicy foods, do not abuse alcohol, avoid preservatives and
dyes.
Be more attentive to the vegetables you eat, they can potentially
contain a large amount of nitrates, nitrites, carcinogens.
Observe the measure in the use of drugs (especially analgesics, antibiotics,
corticoids).
Reduce the negative impact of the environment, harmful chemicals
connections.
Eat more fresh foods rich in vitamins and
trace elements, as well as dairy products.
Follow a normal diet, avoiding too long breaks
between meals, overeating.
Do not smoke.