1. Case Presentation, Management, Discussion and Sharing of Information on Epigastric Pain Jonathan R. Malabanan, M.D. Surgery Resident OMMC DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

2. General Data: L.B. 42 y.o male Quiapo, Manila. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

3. Chief Complaint Epigastric Pain DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

4. History of Present Illness: 1 month PTA→ (+) epigastric pain, on and off associated with postprandial vomiting (+) consult private MD: Ranitidine UTZ: Suspicious tubular density at epigastric region, Normal liver, gall bladder and common bile duct. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

5. →EGD with biopsy: nodular mass at pylorus area multiple erosion from pylorus to the body Biopsy: poorly differentiated gastric adenocarcinoma DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

6. 1 wk PTA →(+)persistence of epigastric pain and post-prandial vomiting with associated anorexia (+) progression of above conditions advised to undergo CT Scan DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

7. →Consulted our hospital due to financial constraint. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

8. PAST MEDICAL HISTORY: No DM No Hypertension No other heredofamilial diseases DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

9. PHYSICAL EXAMINATION: GEN SURVEY: Conscious,coherent,oriented BP=120/80 CR=80 RR=21 T=36.5 HEENT: Pink conjunctivae, anicteric sclerae, no cervical lymphadenopathies CHEST: SCE, clear breath sounds DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

10. PHYSICAL EXAMINATION: PHYSICAL EXAMINATION : CARDIAC: Normal rate, regular rhythm, no murmur ABDOMEN: Flabby, NABS, soft, no palpable mass EXTREMITIES: Full and equal pulses,no deformities DRE: No mass noted, good sphincter tone, with feces on tactating finger DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

11. Salient Features: 42 y.o male (+) epigastric pain, on and off associated with post-prandial vomiting (+) anorexia (+) UTZ: Suspicious tubular density at epigastric region, Normal liver, gall bladder and common bile duct. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

12. Salient Features: (+) EGD with biopsy: nodular mass at pylorus area multiple erosion from pylorus to the body Biopsy: poorly differentiated gastric adenocarcinoma DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

13. Algorithm Epigastric Pain post-prandial vomiting Gastric ulcer Tumor EGD with biopsy: nodular mass on pylorus with mucosal erosion up to the body DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

14. Algorithm Epigastric Pain post-prandial vomiting Gastric ulcer Tumor BenignMalignant Biopsy: poorly differentiated adenocarcinoma DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

15. Clinical Diagnosis DIAGNOSISCERTAINTYTREATMENT PRIMARYGastric AdenoCA Resectable 85%Surgical SECONDARYGastric AdenoCA Non resectable 15%Palliative surgery Chemotherap hy Radiation DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

16. PARACLINICAL DIAGNOSTIC PROCEDURE Do I need a paraclinical diagnostic procedure? Yes. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

17. Paraclinical Diagnostic Options BENEFITRISKCOSTAVAILABI LITY CT ScanSensitivity: 88 % Specificity: 86 %- Lymph node involvement Direct invasion Distant of metastases -RadiationP10- 20 thouNot available Diagnostic Explore Laparotomy Sensitivity: Specificity: May proceed with definitive treatment -Infection -Hemorrhage P30-40 thouAvailable DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery” Bryan J Dicken et. al. Gastric Adenocarcinoma. Review and Considerations for Future Directions. Ann Surg. 2005 January; 241(1): 27–39.

18. Pretreatment Diagnosis: Gastric Adenocarcinoma, Pyloric area, Resectable DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

19. Goals of Treatment 1. Complete removal of gastric cancer 2. Better long term improvement and prevent complication DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

20. Pre Treatment Options BENEFITRISKCOSTAVAILABI LITY Subtotal Gastrectomy Same 5 year survival Shorter hospital stay Better nutritional status -HemorrhageP30-40 thouAvailable Total Gastrectomy 5 year survival -Hemorrhage Increased post operative infection rate P30-40 thouAvailable DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery” Bryan J Dicken et. al. Gastric Adenocarcinoma. Review and Considerations for Future Directions. Ann Surg. 2005 January; 241(1): 27–39. Bozzetti F, Marubini E, Bonfanti G, et al. Subtotal versus total gastrectomy for gastric cancer: five-year survival rates in a multicenter randomized Italian trial. Italian Gastrointestinal Tumor Study Group. Ann Surg. 1999;230:170–178

21. Plan of Operation Subtotal Gastrectomy DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

22. Treatment Goal Better quality of life and increase survival DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

23. Pre Treatment Options BENEFITRISKCOSTAVAILABILI TY Radical Subtotal Gastrectomy with D1 Dissection Recurrence:41 % Hospital Stay: 14 days Infection Rate: 25 % P40 thouAvailable Radical Subtotal Gastrectomy with D2 Dissection Recurrence: 29 % Hospital Stay: 16 days Infection Rate: 43 % P30 thouAvailable DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery” Bonenkamp JJ, Hermans J, Sasako M, et al. Extended lymph-node dissection for gastric cancer. Dutch Gastric Cancer Group. N Engl J Med. 1999;340:908–914. [PubMed

24. Plan of Operation Radical Subtotal Gastrectomy with D2 Dissection, Gastrojejunostomy (Billroth II) DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

25. PREOPERATIVE PREPARATION 1. Informed Consent 2. Psychosocial Support 3. Optimize Patient’s Physical Health 4. Screening For Other Medical Problem 5. Prepare Materials For OR DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

26. Operative Maneuvers Patient supine under GA Asepsis antisepsis Sterile drapes placed Midline vertical abdominal incision long enough to facilitate accurate intra- operative evaluation Liver inspected, stomach identified DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

27. Intraop- findings A nodular mass noted intraluminally at the pylorus area measuring 3x 4 cm No other organ involvement Perigastric and left gastric nodes noted DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

28. Operative Maneuvers Formal radical subtotal gastrectomy done with D2 dissection and removal of omentum Stomach was mobilized with division of right gastroepiploic artery, right gstric and gastrodudenal artery A 6 cm margin tumor margin proximally was allotted removing more than 50% of the stomach DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

29. Operative Maneuvers Formal gastrojejunostomy was done with open end of the stomach attached to the jejunum. Jejunum passed in front of the colon and was attached to the stomach DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

30. Operative Maneuvers - - Hemostasis -OS and instrument checked -Layer by layer closure -Dry sterile dressing placed DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

31. Operation Done: Radical Subtotal Gastrectomy with D2 Dissection, Gastrojejunostomy (Billroth II) DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

32. Final Diagnosis Gastric Adenocarcinoma, Pyloric Area S/P Radical Subtotal Gastrectomy with D2 Dissection, Gastrojejunostomy (Billroth II) DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

33. Post op Management: Maintained on NPO Adequate analgesia given Antibiotics continued Monitoring of early complications DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

34. Post op Management: The nasogastric tube is removed upon return of gastrointestinal transit, and feeding is slowly begun. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

35. Sharing of Information DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

36. Epidemiology -highest incidence is in Japan -occurs more frequently in males in almost all areas of the world -slightly increased risk in patients with blood group A DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

37. Signs & Symptoms produces no specific symptoms when it is superficial and potentially surgically curable, although up to 50% of patients may have nonspecific gastrointestinal complaints such as dyspepsia. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

38. Risk Factors -Diets high in salt and cured and smoked food, low in fresh fruit and vegetable -H. pylori infection -smoking DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

39. Lauren Classification Intestinal Type glandular and arise from the gastric mucosa usually in older patients and more commonly in the distal stomach DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

40. Lauren Classification Diffuse Type - associated with invasive growth pattern and appears to arise from lamina propria -more common in proximal stomach and younger patients DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

41. SURGICAL MANAGEMENT Tumors of the fundus and proximal stomach:  Total gastrectomy with D2 dissection and esophagojejunal reconstruction Tumors of the body:  Total gastrectomy with D2 nodal dissection Tumors of the distal stomach:  Subtotal gastrectomy with D2 nodal dissection DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

42.  In the management of mid to proximal gastric cancers, sparing the tail of the pancreas and the spleen is recommended, if feasible, since it is associated with lesser morbidity and mortality.  D2 resection involves removal of the omental bursa, the hepatoduodenal and retroduodenal nodes (antral lesions) and the splenic artery and hilar nodes and retropancreatic nodes. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

43. ADJUVANT THERAPY  Post-operative Adjuvant chemotherapy: Currently there is not enough evidence that will show benefit for post-operative chemotherapy.  Neo-adjuvant chemotherapy: several studies show promising results but still needs to be studied further. In cases of patients who are candidates for neo-adjuvant chemotherapy, staging using diagnostic laparoscopy is warranted. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

44. FOLLOW-UP  First follow –up within 5 – 7 days after discharge  Second follow-up will be 30 days after the operation.  During the first year, frequency of follow-up will be every 3 months, then every 6 months thereafter.  Yearly endoscopy  Diagnostic work-up will be symptom-directed DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

45. References: Bonenkamp JJ, Hermans J, Sasako M, et al. Extended lymph-node dissection for gastric cancer. Dutch Gastric Cancer Group. N Engl J Med. 1999;340:908–914. Bryan J Dicken et. al. Gastric Adenocarcinoma. Review and Considerations for Future Directions. Ann Surg. 2005 January; 241(1): 27–39. Bozzetti F, Marubini E, Bonfanti G, et al. Subtotal versus total gastrectomy for gastric cancer: five-year survival rates in a multicenter randomized Italian trial. Italian Gastrointestinal Tumor Study Group. Ann Surg. 1999;230:170–178 Cameron, John. Current Surgical Theraphy. Gastric Adenocarcinoma. Pp.95- 100. Treatment Protocol. Department of Surgery. UP- PGH DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

46. MCQ 1.Which of the following characterizes intestinal type of gastric ca? a. associated with invasive growth pattern b. appears to arise from lamina propria c. glandular and arise from gastric mucosa d. more common in proximal stomach e. more common in younger patients DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

47. MCQ 2. Most appropriate surgical treatment for distal gastric ca? a. Total gastrectomy with D2 nodal dissection b. Total gastrectomy with D1 nodal dissection c. Subtotal gastrectomy with D2 nodal dissection d. Total gastrectomy with D2 dissection and esophagojejunal reconstruction e. Subtotal gastrectomy with D1 nodal dissection DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

48. MCQ 3. A classic D2 dissection includes nodes along the following except? a. hepatic b. left gastric c. celiac d. splenic e. periaortic DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

49. MCR Direction: Write “A” if 1, 2, and 3 are valid statements. “B” if only 1 and 3 are valid statements. “C” if only 2 and 4 are valid statements. “D” if only 4 is a valid statement. “E” if all are valid statements. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

50. MCR 4.With regard to the epidemiologic characteristic of gastric ca, which of the following is/are true ? 1. The highest incidence is in Japan 2. Occurs more frequently in males 3. Incidence and death rates in US have decreased 4. Higher incidence among patients with blood group O DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

51. MCR 5. With regard to surgical treatment of gastric adenoCA, which of the following statements is/are true? 1.Total gastrectomy for antral lesions results in longer survival than does partial gastrectomy 2. Total gastrectomy for palliation is contraindicated 3..Extended LN dissection improves survival rates with stage I and II lesions DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

52. MCR 5. With regard to surgical treatment of gastric adenoCA, which of the following statements is/are true? 4. Routine splenectomy does not improve survival rates DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

53. Thank You! DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

54. Journal Appraisal Subtotal Versus Total Gastrectomy for Gastric Cancer Five-Year Survival Rates in a Multicenter Randomized Italian Trial Ann Surg. 1999 August; 230(2): 170. Federico Bozzetti, MD, * Ettore Marubini, PhD, * Giuliano Bonfanti, MD, * Rosalba Miceli, PhD, * Chiara Piano, * Leandro Gennari, MD, * and the Italian Gastrointestinal Tumor Study Groupe. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

55. Objective: – To evaluate the impact of subtotal (SG) versus total (TG) gastrectomy on the oncologic outcome of patients with cancer of the distal stomach from 28 Italian institutions. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

56. Patients and Methods:. The present analysis involved 618 patients randomized during surgery to SG (315) or TG (303), provided there was at least 6 cm from the proximal edge of the tumor to the cardia, there was no intraperitoneal or distant spread, and it was possible to remove the tumor entirely. Both surgical treatments included regional lymphadenectomy. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

57. Results: Four patients died after SG and seven after TG. Median follow-up was 72 months after SG (range 2 to 125) and 75 months after TG (range 7 to 113). Five-year survival probability as computed by the Kaplan-Meier method was 65.3% for SG and 62.4% for TG. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

58. Results: The test of equivalence led to the conclusion that the two procedures may be considered equivalent in terms of 5-year survival probability. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

59. Results: The analysis of survival using a multivariate Cox regression model showed a statistically significant impact on survival of tumor site, tumor spread within the gastric wall, extent of resection to the spleen plus or minus neighboring organs or structures, and relative frequency of metastasis in resected lymph nodes.. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

60. Conclusions: Both procedures have a similar survival probability. The authors believe that SG, which has been reported to be associated with a better nutritional status and quality of life, should be the procedure of choice, provided that the proximal margin of the resection falls in healthy tissue. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

61. Clinical Question: Will total gastrectomy increase the survival of patients with gastric ca on distal half as compared to subtotal gastrectomy? DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

62. Tentative Answer No. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

63. Are the results of the study valid? Primary Guides: 1. Was the assignment of patients to treatment randomized? Yes. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

64. Are the results of the study valid? Primary Guides: 2. Were all patients who entered the trial properly accounted for and attributed at its conclusion? Yes. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

65. Are the results of the study valid? Secondary Guides: 3. Were patients, their clinicians, and study personnel "blind" to treatment? Yes DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

66. Are the results of the study valid? Secondary Guides: 4. Were the groups similar at the start of the trial? Yes. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

67. Are the results of the study valid? Secondary Guides: 5. Aside from the experimental intervention, were the groups treated equally? Yes. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

68. God bless DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”