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GASTRIC CANCER
- SURGERY
Prof. S. Subbiah et al
BLOOD SUPPLY, LIGAMENTS AND LYMPHATICS
Prof. S. Subbiah et al
BLOOD SUPPLY, LIGAMENTS AND LYMPHATICS
Prof. S. Subbiah et al
BLOOD SUPPLY, LIGAMENTS AND LYMPHATICS
Prof. S. Subbiah et al
TREATMENT
• Surgery
• Systemic therapy
• Radiotherapy
SURGERY
SYSTEMIC
THERAPY
GASTRIC
CANCER
RADIO
THERAPY
Cornerstone - Surgery
Prof. S. Subbiah et al
Guidelines and Evidences
Western Japanese
Prof. S. Subbiah et al
Guidelines
Localized
cancer
(cTis or cT1a)
Locoregional
cancer
(cT1b–cT4a)
Metastatic
cancer
(cT4b, cM1)
Prof. S. Subbiah et al
Western guidelines - Summary
Prof. S. Subbiah et al
Guidelines
Non
Metastatic Metastatic
Prof. S. Subbiah et al
Japanese Guidelines - Summary
Prof. S. Subbiah et al
T1a
Prof. S. Subbiah et al
Endoscopic Resection
Prof. S. Subbiah et al
EMR & ESD
Prof. S. Subbiah et al
Endoscopic Resection Vs Gastrectomy
Wang et al-
Meta analysis
• No difference in OS
• Shorter hospital stay and
reduced perioperative
morbidity with ER
Prof. S. Subbiah et al
Endoscopic Resection
Endoscopic
Resection
Evaluation
of Curability
Treatment &
Surveillance
Prof. S. Subbiah et al
Endoscopic Resection - Curability
UL - Ulceration
SM 1 - <500microns
from m.mucosa
VM - Vertical margin
HM - Horizontal margin
LyV - Lymphovascular
invasion
Prof. S. Subbiah et al
T1a - Surgery
• Tumors that do not meet the criteria for EMR/ESD
• Proximal or Pylorus preserving Gastrectomy
• D1 lymphadenectomy
• No role for nodal sampling or SLN Mapping
Prof. S. Subbiah et al
T1a - Surgery
Proximal Gastrectomy Pylorus preserving Gastrectomy
Prof. S. Subbiah et al
T1a - Surgery
Local Resection Segmental Gastrectomy
Non Standard Treatment
( Investigational )
Prof. S. Subbiah et al
T1b
Prof. S. Subbiah et al
T1b
• Gastrectomy – depending upon the tumor site
• D1 Lymphadenectomy –
Differentiated type &
1.5 cm or smaller
• D1+ lymphadenectomy – all other T1b tumors
Prof. S. Subbiah et al
T1b
Prof. S. Subbiah et al
Sentinel lymph node biopsy
• Inappropriate for clinical use in Early gastric cancer
Prof. S. Subbiah et al
Locoregional cancer T2-4
Prof. S. Subbiah et al
T2-4
Prof. S. Subbiah et al
Criteria of Unresectability
• Locoregionally advanced
o Disease infiltration of the root of the mesentery
o Para-aortic lymph node highly suspicious on imaging or confirmed by biopsy
o Invasion or encasement of major vascular structures
(excluding the splenic vessels)
• Distant metastasis or peritoneal seeding (including positive peritoneal cytology)
Prof. S. Subbiah et al
Locoregional cancer – T2 and above, any N
Medically fit and potentially resectable
Loco regional
• Surgery or Periop Chemo or Preop ChemoRT
Medically fit and unresectable
Loco regional
• Chemoradiation or Systemic therapy
Non surgical candidates
Loco regional
• Palliative/Best supportive care
Prof. S. Subbiah et al
Staging Laparoscopy and Peritoneal cytology
• Staging laparoscopy should be done before surgery, as CT cannot detect
peritoneal metastasis with <5mm size.
• Unnecessary laparotomies can be avoided in 38% (Muntean et al)
• It allows assessment of peritoneal cytology and laparoscopic ultrasound
• NCCN recommends diagnostic laparoscopy for patients with resectable stage
cT1b or higher locoregional disease
Prof. S. Subbiah et al
Surgery for Locoregional Cancer
• Gastric Resection
• Lymphadenectomy
• Reconstruction
Prof. S. Subbiah et al
Surgery for Locoregional Cancer
Standard
Gastrectomy
Total Gastrectomy
D2
lymphadenectomy
Subtotal
Gastrectomy
D2
lymphadenectomy
Non Standard
Gastrectomy
Multi organ
resection
Extended
lymphadenectomy
Prof. S. Subbiah et al
Standard Gastrectomy
TOTAL GASTRECTOMY SUBTOTAL GASTRECTOMY
Prof. S. Subbiah et al
Margin
 PROXIMAL MARGIN
• T1 tumours - 2cm
• T2 or deeper - 3cm for expansive growth pattern (type 1 & 2)
5cm for infiltrative growth pattern (type 3 & 4)
 DISTAL MARGIN
Distal to pylorus
Subtotal Gastrectomy is done when a satisfactory proximal resection margin can
be obtained
Prof. S. Subbiah et al
Total Vs Subtotal Gastrectomy
Angelov et al – Comparable oncological outcome
Prof. S. Subbiah et al
Lymphadenectomy
Japanese Vs Western
D2 or 16 nodes ?
Prof. S. Subbiah et al
Lymphadenectomy - East
• D2 for cN+ or ≥ cT2
• D2 lymphadenectomy should be performed whenever the
possibility of nodal involvement cannot be dismissed.
Prof. S. Subbiah et al
Lymphadenectomy - East
Prof. S. Subbiah et al
D2+ Lymphadenectomy
• Dissection of No. 10 with or without splenectomy
• Dissection of No. 13 for cancer invading the duodenum
Prof. S. Subbiah et al
Para aortic node dissection (PAND)
• Bulky D1 or D2 nodes
• Para aortic node + disease without other unresectable factors –
Neoadjuvant therapy followed by D2 lymphadenectomy and PAND
• Routine PAND ?
No survival advantage
Prof. S. Subbiah et al
Lymphadenectomy - West
• Gastrectomy with a D1 or a modified D2 lymph node dissection, with a goal of
examining 16 or more lymph nodes
• D2 lymph node dissections should be performed by experienced surgeons in
high-volume centers
• Trials
 Dutch Gastric cancer group trial
 Medical Research council (MRC) Trial -UK
 Italian Gastric cancer study group
Prof. S. Subbiah et al
Prof. S. Subbiah et al
Bursectomy
• No survival benefit
Prof. S. Subbiah et al
Splenectomy
Routine splenectomy is not indicated unless the spleen is involved
or extensive hilar adenopathy is noted
Prof. S. Subbiah et al
West meets East – D2 lymphadenectomy
Prof. S. Subbiah et al
Minimally Invasive surgery
• Non inferiority in terms of oncological outcomes
• Early Gastric Cancer vs Locally advanced GC
• KLASS-01 trial and JCOG 0703
• KLASS-02 trial
Prof. S. Subbiah et al
Minimally Invasive surgery
Trials revealed similar overall and
cancer-specific survival rates
between patients receiving
laparoscopic and open distal
gastrectomy in EGC
Prof. S. Subbiah et al
Minimally Invasive Surgery
• Locally advanced cancer – Non inferiority trial
• 3 Year DFS – Comparable
• Could be a potential standard treatment option for LAGC
Prof. S. Subbiah et al
Multi-organ Resection
Can be performed for R0 Resection in T4b tumours
Prof. S. Subbiah et al
Reconstruction after Total Gastrectomy
Prof. S. Subbiah et al
Reconstruction after Total Gastrectomy
Prof. S. Subbiah et al
Palliative Surgery
Modified Devines
Prof. S. Subbiah et al
Endoscopy in palliation
Prof. S. Subbiah et al
SEMS VS GJ
• Patients with acceptable PS should be primarily considered for a
palliative GJ rather than stenting
• Life expectancy > 2 months – GJ preferable
Prof. S. Subbiah et al
Take home message
• Endoscopic resection vs Surgery
• Total Vs subtotal Gastrectomy
• Lymphadenectomy D2 vs D1
• SLNB
• Bursectomy
• Splenectomy
• Multiorgan resection
• PAND
• Lap Vs open Surgery
• Reconstruction - Pouch
• Palliative surgery – GJ vs SEMS
Prof. S. Subbiah et al
THANK YOU
Prof. S. Subbiah et al

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Editor's Notes

  1. These are the derivatives of ventral and dorsal mesogastrium and carry the principal blood vessels of the stomach. Knowledge of these ligaments is necessary for us to identify and ligate these vessels at their origin
  2. From there we have moved on to the concept of lymph nodal stations. Where the west were recommending to go by the number of nodes, the eastern concept was centered around the location of metastasis.
  3. The japanese research society classified the nodes around the stomach as regional nodes or N1 nodes, other regional or N2 nodes, distant or N3 nodes. These distant nodes were still not considered to be metastatic ones
  4. Ct cannot identify low volume peritoneal microscopic metastasis that are <5mm in size