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General Surgery
Perspective on Gastric Cancer
Built from Maingot's Abdominal Operations
What’s inside
8 sections · 63 slides
Overview
- What this topic covers
- Regions of the stomach
- Gastrectomy, dissection and node stations defined
How much lymph node dissection
The trials behind D2 as the standard operation
- D1 and D2 dissection compared
- The controversy over the extent of dissection
- The first three randomised trials
- Quality control in the MRC trial
- How surgical quality shapes a trial result
- The Dutch D1 versus D2 trial
- Fifteen-year results of the Dutch trial
- Limitations of the Dutch trial
- Nodal dissection in the Taiwanese trial and in reanalyses
- Reliability of the D1 versus D2 meta-analyses
- ~10%
- Trials comparing D1 with D2 dissection
Safe surgical margin
How much normal stomach to leave beyond the tumour
- The resection margin
- Margins for T2 or deeper tumours
- Frozen section when the rule cannot be applied
- Margins for T1 tumours
- Opened stomach carrying an ulcerated tumour
- Extent of a distal gastrectomy
Laparoscope-assisted gastrectomy
Where the keyhole operation stands, and what it cannot yet claim
- Laparoscope-assisted gastrectomy in current practice
- Randomised trials of LAG versus open gastrectomy
- Limitations of the laparoscopic approach
- Recurrence risk specific to gastric cancer
Membranes, mesenteries and node stations
The anatomy that makes a clean gastric dissection possible
- The guiding principle of gastric lymphadenectomy
- Membranes that carry the vessels of the stomach
- The two mesenteries of the stomach
- What rotation of the gut turns the mesenteries into
- Arteries arising in the ventral mesogastrium
- Arterial supply of the stomach
- Lymph node stations and vessels around the stomach
- The Japanese node station numbering
- Development of the omentum, mesogastrium and mesoduodenum
- Blood supply of the antrum and duodenal bulb
- ~50%
- Clearing the infrapyloric station
- Vessels and nodes at the origin of the right gastroepiploic vessels
- Henle's common trunk
- Development and fusion of the greater omentum
- Complete omentectomy and the bursa omentalis
Nodes you cannot see, nerves worth keeping
Why whole stations are cleared rather than suspicious nodes picked
- Metastatic nodes that look normal
- Nodes fixed to membranes or to nerve sheaths
D2 dissection without splenectomy
Working through the splenic hilum and keeping the spleen
- Dissection of the splenic vessels and hilum
- Variation in the posterior gastric artery
- Short gastric and left gastroepiploic arteries
- Layer containing the splenic hilar nodes
- Splenic vessels and nodes near the root of the splenic artery
- Why resection of the pancreatic tail and spleen was abandoned
Reconstruction after distal gastrectomy
Rebuilding the route for food, and the authors' preferred method
- What has to be rebuilt after a distal gastrectomy
- Reconstruction by gastroduodenostomy
- Reconstruction by gastrojejunostomy
- Gastroduodenostomy compared with Roux-en-Y
- The authors' preferred reconstruction
- Roux-en-Y stasis
- Mechanism proposed for Roux-en-Y stasis
- Construction of the retrocolic Roux-en-Y
- Why fixing the stomach to the mesocolic window helps
- Key points: dissection and margins
- Key points: anatomy and reconstruction
- References
- References (continued)
- Maingot's Abdominal Operations, 12th Edition