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   Abdominal (Gastric Cancer) - Ahmad Abid
   Solid organ (HCC) – Ahmad Ashraf
   Upper extremities – Ahmad Danial
   Lower extremities – Ahmad Farabi
   Head and Neck- Adiba & Adibah
   General – Khaireza (state of consciousness and hemorrhage)
Ahmad Abid Bin Abas 07-6-2
Oncological Emergency : Gastric Cancer
Oncological Emergency : Gastric Cancer
More prominent in case of advanced gastric
 cancer.

   Early satiety,bloating,distension and vomiting may
    occur.
   If tumour bleeds will lead to iron def. anemia.
   Obstruction will lead to dysphagia,epigastric fullness or
    vomiting.
   With pyloric involvement will lead to gastric outlet obst.
   Metastatic LN may be palpable (Virchow’s Nodes)
   Medical Hx/Phys. Exam (Signs and symptoms)
   Lab tests – CBC, LFT,RFT,Carcinoembryonic
    Ag. and CA19.9
   EGD and Biopsy,EUS guided biopsy,CT guided
    needle biopsy.
   Imaging – Barium Swallow,CT Scan,MRI,CXR
    for metastatic lesion.
   Surgery,Chemotherapy,Radiation,LN Removal
    D1,D2.
Oncological Emergency : Gastric Cancer
    Emergency surgery within 24h of
     presentation for gastric malignancy is
     extremely rare.
    Presentation :
1.    Haematemesis
2.    Visceral perforation
3.    Gastric Outlet Obstruction
     PE : Severe abdomen tenderness suggests GI
      bleeding assoc. with GI Obst,GI perforation
      and bowel ischemia.
    Two-staged procedural approach.
1.    First stage – Control the perforation,bleeding
      and obstruction.
      (Emergency lifesaving intervention)
2.    Second stage – Definitive gastrectomy with
      LN dissection after histological confirmation
      and accurate staging.
      (Emergency cancer therapy)
   Nasogastric aspiration with saline lavage.
    (Detection intragastric bleeding,type of bleeding-
    red blood/coffee ground,endoscopic
    visualization,prevent aspiration of gastric
    contents.)
   General Measure : (fluid replacement,blood
    transfusion,care of abdomen from further
    trauma,cardiorespiratory support,Rx
    comorbid disease like sepsis,coronary artery
    disease.)
   *EGD should be delayed until patient is adequately
    resuscitated and stabilized.
    Specific measures : EGD          (procedure of choice,diagnostic
     and therapeutic tool for UGIB)
1.    Injection therapy (adrenaline)
2.    Ablative therapy (electrocautery,argon
      plasma coagulation)
3.    Mechanical therapy (endoclips or banding)
     May require surgery for bleeding control if
      endoscopic measures for hemostasis fail.
1.   Endoscopic stenting




http://www.hopkins-gi.org/GDL_Disease.aspx?CurrentUDV=31&GDL_Cat_ID=AF793A59-B736-42CB-9E1F-
    E79D2B9FC358&GDL_Disease_ID=DB2F8EAC-4421-41DD-B04E-684AFEF2AD94
    (Surgical) :
1.    Surgical bypass with gastrojejunostomy.
2.    Palliative distal gastrectomy.
   Exploratory laparotomy and application of Omental patch (Graham patch)
   Peritoneal washout - peritoneal cavity is to be irrigated with 10 liters of warm
    saline solution to remove further contamination.




http://www.saudijgastro.com/article.asp?issn=1319-
    3767;year=2011;volume=17;issue=2;spage=124;epage=128;aulast=Maghsoudi
   Closed suction drainage/Jacksonn Patt drain placement.
   Site : suprahepatic and infrahepatic recesses, the lesser sac,
    the paracolic gutters, and pelvis.
   Crystalloid solutions.
   The goals of resuscitation focus on urinary
    output, lactic acid levels, mean arterial
    pressure, and central venous pressure
    parameters.
   Jejunostomy feeding tube.




   http://www.uofmmedicalcenter.org/healthlibrary/Article/86497
   Oral feeding is likely to be delayed.
   Intraoperative placement of a jejunostomy
    feeding tube may be benefit the patient.
   Alternative : Intraoperative or postoperative
    placement of a double lumen gastro-jejunal
    tube.
   Catheters - Parenteral nutrition sometimes used.
   *Generally, enteral nutrition distal to the perforation would be
    preferable if possible.

   http://emedicine.medscape.com/article/1892935-overview#aw2aab6b5
   http://patients.gi.org/topics/enteral-and-parenteral-nutrition/
   “Antimicrobial therapy should be continued postoperatively
    for 24 hours when the perforation has been surgically closed
    in the first 12 hours” - Infectious Guidelines of the Disease Society of
    America and Surgical Infection Society

   Goals : Normalization of WBC counts and temperature after
    24h postoperatively.
   If does not occur,antimicrobials can be continued for 4-7
    days.
   Preferred agents include a beta-lactam/beta-lactamase
    inhibitor combination or a carbapenem.

   H pylori eradication should also be considered.

http://emedicine.medscape.com/article/1892935-overview#aw2aab6b5
   Following patient recovery and histological
    confirmation of malignancy, accurate disease
    staging can be completed, and a radical
    oncological operation for gastric cancer or
    neoadjuvant chemotherapy can be planned as
    appropriately.

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Oncological Emergency : Gastric Cancer

  • 1. Abdominal (Gastric Cancer) - Ahmad Abid  Solid organ (HCC) – Ahmad Ashraf  Upper extremities – Ahmad Danial  Lower extremities – Ahmad Farabi  Head and Neck- Adiba & Adibah  General – Khaireza (state of consciousness and hemorrhage)
  • 2. Ahmad Abid Bin Abas 07-6-2
  • 5. More prominent in case of advanced gastric cancer.  Early satiety,bloating,distension and vomiting may occur.  If tumour bleeds will lead to iron def. anemia.  Obstruction will lead to dysphagia,epigastric fullness or vomiting.  With pyloric involvement will lead to gastric outlet obst.  Metastatic LN may be palpable (Virchow’s Nodes)
  • 6. Medical Hx/Phys. Exam (Signs and symptoms)  Lab tests – CBC, LFT,RFT,Carcinoembryonic Ag. and CA19.9  EGD and Biopsy,EUS guided biopsy,CT guided needle biopsy.  Imaging – Barium Swallow,CT Scan,MRI,CXR for metastatic lesion.
  • 7. Surgery,Chemotherapy,Radiation,LN Removal D1,D2.
  • 9. Emergency surgery within 24h of presentation for gastric malignancy is extremely rare.  Presentation : 1. Haematemesis 2. Visceral perforation 3. Gastric Outlet Obstruction  PE : Severe abdomen tenderness suggests GI bleeding assoc. with GI Obst,GI perforation and bowel ischemia.
  • 10. Two-staged procedural approach. 1. First stage – Control the perforation,bleeding and obstruction. (Emergency lifesaving intervention) 2. Second stage – Definitive gastrectomy with LN dissection after histological confirmation and accurate staging. (Emergency cancer therapy)
  • 11. Nasogastric aspiration with saline lavage. (Detection intragastric bleeding,type of bleeding- red blood/coffee ground,endoscopic visualization,prevent aspiration of gastric contents.)
  • 12. General Measure : (fluid replacement,blood transfusion,care of abdomen from further trauma,cardiorespiratory support,Rx comorbid disease like sepsis,coronary artery disease.)  *EGD should be delayed until patient is adequately resuscitated and stabilized.
  • 13. Specific measures : EGD (procedure of choice,diagnostic and therapeutic tool for UGIB) 1. Injection therapy (adrenaline) 2. Ablative therapy (electrocautery,argon plasma coagulation) 3. Mechanical therapy (endoclips or banding)  May require surgery for bleeding control if endoscopic measures for hemostasis fail.
  • 14. 1. Endoscopic stenting http://www.hopkins-gi.org/GDL_Disease.aspx?CurrentUDV=31&GDL_Cat_ID=AF793A59-B736-42CB-9E1F- E79D2B9FC358&GDL_Disease_ID=DB2F8EAC-4421-41DD-B04E-684AFEF2AD94
  • 15. (Surgical) : 1. Surgical bypass with gastrojejunostomy. 2. Palliative distal gastrectomy.
  • 16. Exploratory laparotomy and application of Omental patch (Graham patch)  Peritoneal washout - peritoneal cavity is to be irrigated with 10 liters of warm saline solution to remove further contamination. http://www.saudijgastro.com/article.asp?issn=1319- 3767;year=2011;volume=17;issue=2;spage=124;epage=128;aulast=Maghsoudi
  • 17. Closed suction drainage/Jacksonn Patt drain placement.  Site : suprahepatic and infrahepatic recesses, the lesser sac, the paracolic gutters, and pelvis.
  • 18. Crystalloid solutions.  The goals of resuscitation focus on urinary output, lactic acid levels, mean arterial pressure, and central venous pressure parameters.
  • 19. Jejunostomy feeding tube.  http://www.uofmmedicalcenter.org/healthlibrary/Article/86497
  • 20. Oral feeding is likely to be delayed.  Intraoperative placement of a jejunostomy feeding tube may be benefit the patient.  Alternative : Intraoperative or postoperative placement of a double lumen gastro-jejunal tube.  Catheters - Parenteral nutrition sometimes used.  *Generally, enteral nutrition distal to the perforation would be preferable if possible.  http://emedicine.medscape.com/article/1892935-overview#aw2aab6b5  http://patients.gi.org/topics/enteral-and-parenteral-nutrition/
  • 21. “Antimicrobial therapy should be continued postoperatively for 24 hours when the perforation has been surgically closed in the first 12 hours” - Infectious Guidelines of the Disease Society of America and Surgical Infection Society  Goals : Normalization of WBC counts and temperature after 24h postoperatively.  If does not occur,antimicrobials can be continued for 4-7 days.  Preferred agents include a beta-lactam/beta-lactamase inhibitor combination or a carbapenem.  H pylori eradication should also be considered. http://emedicine.medscape.com/article/1892935-overview#aw2aab6b5
  • 22. Following patient recovery and histological confirmation of malignancy, accurate disease staging can be completed, and a radical oncological operation for gastric cancer or neoadjuvant chemotherapy can be planned as appropriately.