Case Presentation, Management, Discussion and Sharing of Information on Epigastric Pain

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

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

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

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

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

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

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

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

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

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

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

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

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

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

15. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery” Clinical Diagnosis

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

17. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery” Paraclinical Diagnostic Options Bryan J Dicken et. al. Gastric Adenocarcinoma. Review and Considerations for Future Directions. Ann Surg. 2005 January; 241(1): 27–39.

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

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

20. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery” Pre Treatment Options 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. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery” Plan of Operation • Subtotal Gastrectomy

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

42. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery” • 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.

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

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

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

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

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

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

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

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