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Surgery_Schwartz. specimens, even in patients without a preoperative diagnosis of carcinoma, affirming the role of early intervention. Surgery should be conducted with the aim of complete extirpation of the stomach to squamous lined esophagus proximally and normal duodenal mucosa distally. Mutation-carrying females are also at increased risk of breast cancer, most often lobular carcinomas, and should be carefully monitored.Up to 10% of gastric cancer cases appear to be familial without a clear-cut genetic diagnosis. First-degree relatives of patients with gastric cancer have a twoto threefold increased risk of developing the disease. Patients with hereditary nonpol-yposis colorectal cancer have a 10% risk of developing gastric cancer, predominantly the intestinal subtype. The mucous cell hyperplasia of Ménétrier’s disease is generally considered to carry a 5% to 10% risk of adenocarcinoma. Periodic surveil-lance EGD is prudent in all the aforementioned conditions. The glandular hyperplasia associated


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Surgery_Schwartz. disease is generally considered to carry a 5% to 10% risk of adenocarcinoma. Periodic surveil-lance EGD is prudent in all the aforementioned conditions. The glandular hyperplasia associated with gastrinoma is not prema-lignant, but ECL hyperplasia and/or carcinoid tumors can occur.PathologyDysplasia It is generally accepted that gastric dysplasia is the universal precursor to gastric adenocarcinoma. Patients with severe dysplasia should be considered for gastric resection if the abnormality is widespread or multifocal, or EMR if the severe dysplasia is localized. Patients with mild dysplasia should be followed with endoscopic biopsy surveillance, and Helicobacter eradication.Early Gastric Cancer Early gastric cancer is defined as adeno-carcinoma limited to the mucosa (T1a) and submucosa (T1b) of the stomach. The entity is common in Asia, where the higher frequency of gastric cancer justified adoption of aggressive surveillance programs. Approximately 10% of patients clini-cally staged


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Surgery_Schwartz. of the stomach. The entity is common in Asia, where the higher frequency of gastric cancer justified adoption of aggressive surveillance programs. Approximately 10% of patients clini-cally staged with early gastric cancer will have lymph node metastases. There are several subtypes of early gastric cancer (Table 26-17 and Fig. 26-55). Approximately 70% of early gas-tric cancers are well differentiated, and 30% are poorly differen-tiated. The overall cure rate with adequate gastric resection and lymphadenectomy is 95%. In some Japanese centers, 50% of the gastric cancers treated are early stage (compared to less than 20% of resected gastric adenocarcinomas in the United States). Selected patients with early gastric cancer can be treated with endoscopic resection.150Table 26-17Macroscopic types of superficial gastric cancerType 0-I (protruding)aPolypoid tumorsType 0-II (superficial)Tumors with or without minimal elevation or depression relative to the surrounding mucosa Type


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Surgery_Schwartz. types of superficial gastric cancerType 0-I (protruding)aPolypoid tumorsType 0-II (superficial)Tumors with or without minimal elevation or depression relative to the surrounding mucosa Type 0-IIaSlightly elevated tumors (superficial elevated) Type 0-IIbTumors without elevation or depression (superficial flat) Type 0-IIcSlightly depressed tumors (superficial depressed)Type 0-III (excavated)Tumors with deep depressionaTumors with less than 3-mm elevation are usually classified as–IIa, with more elevated tumors being classified as 0-I.Figure 26-54. Complete intestinal metaplasia of the stomach. Note intestinal type crypts lined with goblet cells and intestinal absorptive cells. (Used with permission from Kristen Stashek, MD.)Brunicardi_Ch26_p1099-p1166.indd 114301/03/19 7:12 PM 1144SPECIFIC CONSIDERATIONS PART IIGross Morphology and Histologic Subtypes Gastric cancer has been subdivided into four morphologic subtypes: polypoid, fungating, ulcerative, and scirrhous. The first two


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Surgery_Schwartz. CONSIDERATIONS PART IIGross Morphology and Histologic Subtypes Gastric cancer has been subdivided into four morphologic subtypes: polypoid, fungating, ulcerative, and scirrhous. The first two are character-ized by a largely intraluminal mass. Polypoid tumors are not ulcerated; fungating tumors are predominantly intraluminal with ulceration. In the latter two gross subtypes, the bulk of the tumor mass is confined to the wall of the stomach. Ulcerative tumors are self-descriptive. Scirrhous tumors infiltrate the entire thickness of the stomach and cover a very large surface area, commonly involve the entire stomach and have a particularly poor prognosis. Although these latter lesions may be technically resectable with total gastrectomy, it is common for both the esophageal and duodenal margins of resection to show micro-scopic evidence of tumor infiltration; distant metastasis, overt or occult, is frequent and death from recurrent disease within 6 months is common. Palliative


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Surgery_Schwartz. margins of resection to show micro-scopic evidence of tumor infiltration; distant metastasis, overt or occult, is frequent and death from recurrent disease within 6 months is common. Palliative chemotherapy may prolong median survival.151The location of the primary tumor in the stomach is essen-tial in planning an operation. Several decades ago, the large majority of gastric cancers were in the distal stomach. Recently, there has been a proximal migration of tumors, so currently, the distribution is closer to 40% distal, 30% middle, and 30% proximal.Histology The most important prognostic indicators in gastric cancer are both histologic: lymph node involvement and depth of tumor invasion. Tumor grade (degree of differentiation: well, moderately, or poorly) is also important prognostically.There are several histologic classifications of gastric cancer. The World Health Organization recognizes several histologic types (Table 26-18). The Japanese classification is similar but more


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Surgery_Schwartz. are several histologic classifications of gastric cancer. The World Health Organization recognizes several histologic types (Table 26-18). The Japanese classification is similar but more detailed. The commonly used Lauren classifi-cation separates gastric cancers into intestinal type (53%), dif-fuse type (33%), and unclassified (14%). The intestinal type is associated with chronic atrophic gastritis, severe intestinal meta-plasia, and dysplasia, and tends to be less aggressive than the diffuse type. The diffuse type of gastric cancer is more likely to be poorly differentiated and is associated with younger patients and proximal tumors. The Ming classification also is useful and easy to remember, with only two types—expanding (67%) and infiltrative (33%).Recently, the significance of human epidermal growth factor receptor-2 (HER2) was reported in patients with gastric cancer. In breast cancer, overexpression of HER2 has been reported in 15% to 25% of cases, and it is well recognized as


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Surgery_Schwartz. epidermal growth factor receptor-2 (HER2) was reported in patients with gastric cancer. In breast cancer, overexpression of HER2 has been reported in 15% to 25% of cases, and it is well recognized as an unfavorable prognostic factor. The development of molecular targeted agents such as trastuzumab has improved the survival of HER2-positive patients. Likewise, in gastric cancer, HER2 overexpression has been reported in 13% to 30% of patients. HER2 targeting with trastuzumab resulted in improved survival in patients with stage IV gastric cancer, and immunohistochem-istry (IHC) staining for HER2 should be performed in recurrent or metastatic cases.152 Expression of other growth receptors in gastric cancer have been characterized as well, including HER1 (epidermal growth factor rector) and HER3. The latter is associ-ated with poor prognosis, but efforts to target these receptors for therapeutic benefit are still exploratory.153Pathologic Staging Ultimately, prognosis is related to


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Surgery_Schwartz. and HER3. The latter is associ-ated with poor prognosis, but efforts to target these receptors for therapeutic benefit are still exploratory.153Pathologic Staging Ultimately, prognosis is related to patho-logic stage. The most widespread system for staging of gastric cancer is the tumor-node-metastasis (TNM) staging system based on depth of tumor invasion, extent of lymph node metastases, and presence of distant metastases. This system was developed by the American Joint Committee on Cancer and the International Union Against Cancer, and it has under gone several modifications since it was originally conceived (Table 26-19).Clinical Manifestations. Most patients who are diagnosed with gastric cancer in the United States have advanced stage III or IV disease at the time of diagnosis. The most common symp-toms are weight loss and decreased food intake due to anorexia and early satiety. Abdominal pain (usually not severe and often ignored) is also common. Other symptoms include nausea,


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Surgery_Schwartz. most common symp-toms are weight loss and decreased food intake due to anorexia and early satiety. Abdominal pain (usually not severe and often ignored) is also common. Other symptoms include nausea, vomit-ing, and bloating. Acute GI bleeding is somewhat unusual (5%), but chronic occult blood loss is common and manifests as iron Type IIaType IType IIBType IIcType IIIExcavatedDepressedFlatElevatedProtrudedFigure 26-55. Pathologic types of early gastric cancer. (Repro-duced with permission from Fenoglio-Preiser CM, Noffsinger AE, Belli J, et al: Pathologic and phenotypic features of gastric cancer, Semin Oncol. 1996 Jun;23(3):292-306.)Table 26-18World Health Organization histologic typing of gastric cancerAdenocarcinoma Papillary adenocarcinoma Tubular adenocarcinoma Mucinous adenocarcinoma Signet-ring cell carcinomaAdenosquamous carcinomaSquamous cell carcinomaSmall cell carcinomaUndifferentiated carcinomaOthersReproduced with permission from Ming S-C, Goldman H: Pathology of the


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Surgery_Schwartz. cell carcinomaAdenosquamous carcinomaSquamous cell carcinomaSmall cell carcinomaUndifferentiated carcinomaOthersReproduced with permission from Ming S-C, Goldman H: Pathology of the Gastrointestinal Tract, 2nd ed. Baltimore, MD: Williams & Wilkins; 1998.Brunicardi_Ch26_p1099-p1166.indd 114401/03/19 7:12 PM 1145STOMACHCHAPTER 26deficiency anemia and heme-positive stool. Dysphagia is com-mon if the tumor involves the cardia of the stomach. Paraneoplas-tic syndromes such as Trousseau’s syndrome (thrombophlebitis), acanthosis nigricans (hyperpigmentation of the axilla and groin), or peripheral neuropathy are rarely present.Physical examination typically is normal. Other than signs of weight loss, specific positive physical findings usually indi-cate incurability. A focused examination in a patient in whom gastric cancer is a likely part of the differential diagnosis should include an examination of the neck, chest, abdomen, and rectum. Cervical, supraclavicular (on the left referred


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Surgery_Schwartz. a patient in whom gastric cancer is a likely part of the differential diagnosis should include an examination of the neck, chest, abdomen, and rectum. Cervical, supraclavicular (on the left referred to as Virchow’s node), and axillary lymph nodes may be enlarged, and can be sampled with fine-needle aspiration cytology. Malignant pleural effusions or ascites, or aspiration pneumonitis may be present. An abdominal mass may indicate a large (usually T4) primary tumor, liver metastases, or carcinomatosis (including Kruken-berg’s tumor of the ovary). A palpable umbilical nodule (Sister Joseph’s nodule) is pathognomonic of advanced disease. Rec-tal exam may reveal heme-positive stool and hard nodularity extraluminally and anteriorly, indicating so-called drop metas-tases, or rectal shelf of Blumer in the pouch of Douglas.Diagnostic Evaluation. Distinguishing between peptic ulcer and gastric cancer on clinical grounds alone can be difficult. Patients over the age of 55 years who have


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Surgery_Schwartz. of Blumer in the pouch of Douglas.Diagnostic Evaluation. Distinguishing between peptic ulcer and gastric cancer on clinical grounds alone can be difficult. Patients over the age of 55 years who have new-onset dyspep-sia as well as all patients with dyspepsia and alarm symptoms (weight loss, recurrent vomiting, dysphagia, evidence of GI bleeding, or anemia) or with a family history of gastric cancer should undergo prompt upper endoscopy and biopsy if a muco-sal lesion is noted. Essentially, all patients in whom gastric can-cer is part of the differential diagnosis should have endoscopy and biopsy. If suspicion for cancer is high and the biopsy is negative, the patient should be reendoscoped and more aggres-sively biopsied. In some patients with gastric tumors, upper GI series can be helpful in planning treatment. Although a good double-contrast barium upper GI examination is sensitive for gastric tumors (up to 75% sensitive), in most centers, endos-copy has become the gold standard for


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Surgery_Schwartz. in planning treatment. Although a good double-contrast barium upper GI examination is sensitive for gastric tumors (up to 75% sensitive), in most centers, endos-copy has become the gold standard for the diagnosis of gastric malignancy. In addition, recent advances in endoscopy have contributed to the earlier diagnosis of gastric cancer. Magnify-ing endoscopy with narrow-band imaging (NBI) has undergone technological improvements and can observe the microvascu-lar architecture of the mucosa and microsurface pattern of the lesion. Magnifying endoscopy with NBI has been reported to be accurate and reliable in the diagnosis of early gastric cancer.154Preoperative staging of gastric cancer is best accomplished with abdominal/pelvic CT scanning with IV and oral contrast. MRI is probably comparable. The best way to stage the tumor locally is via EUS, which gives fairly accurate (80%) informa-tion about the depth of tumor penetration into the gastric wall, and can usually show enlarged (>5


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Surgery_Schwartz. The best way to stage the tumor locally is via EUS, which gives fairly accurate (80%) informa-tion about the depth of tumor penetration into the gastric wall, and can usually show enlarged (>5 mm) perigastric and celiac lymph nodes. However, there are limitations to tumor staging with EUS. It is highly operator dependent and may underes-timate lymph node involvement because normal-sized nodes (<5 mm) can harbor metastases. EUS is most accurate in distin-guishing early gastric cancer (T1) from more advanced tumors.Positron Emission Tomography Scanning Whole-body PET scanning derives its power from the preferential accumulation of positron-emitting 18F-fluorodeoxy glucose in tumor com-pared to nontumor cells. It is most useful in the evaluation of distant metastasis in gastric cancer, but it can also be useful in locoregional staging. PET scan is accurate when combined with spiral CT (PET-CT)155 and should be considered before major surgery in patients with particularly high-risk or


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Surgery_Schwartz. it can also be useful in locoregional staging. PET scan is accurate when combined with spiral CT (PET-CT)155 and should be considered before major surgery in patients with particularly high-risk or locally advanced tumors.Staging Laparoscopy and Peritoneal Cytology Laparoscopy has emerged as a valuable adjunct to gastric cancer staging, par-ticularly in patients with more substantial tumors. This modality allows for rapid identification of macrosopic peritoneal metas-tases. Peritoneal lavage identifies an additional subset of patients with microscopic dissemination. The prognostic 5Table 26-19AJCC Staging Classification for 8th EditionsAJCC 8TH EDITIONSTAGETNMIAT1N0M0IBT2N0M0T1N1M0IIAT3N0M0T2N1M0T1N2M0IIBT4aN0M0T3N1M0T2N2M0T1N3aM0IIIAT4bN1M0T4aN1M0T4aN2M0T3N2M0T2N3aM0IIIBT4bN1M0T4bN2M0T4aN3aM0T3N3aM0T2N3bM0T1N3bM0IIICT4bN3aM0T4bN3bM0T4aN3bM0T3N3bM0IVAny TAny NM1T1 Tumor invades lamina propria, muscularis mucosa, or submucosa, T2 Tumor invades muscularis propria, T3 Tumor penetrates


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Surgery_Schwartz. TAny NM1T1 Tumor invades lamina propria, muscularis mucosa, or submucosa, T2 Tumor invades muscularis propria, T3 Tumor penetrates subserosal connective tissue without invasion of visceral peritoneum or adjacent structures, T4a Tumor invades serosa (visceral peritoneum), T4b: Tumor invades adjacent structures, N0 No regional lymph node metastasis, N1 Metastasis in 1-2 regional lymph nodes, N2: Metastasis in 3-6 regional lymph nodes, N3: Metastasis in 7 or more regional lymph nodes, N3a: Metastasis in 7-15 regional lymph nodes N3b: Metastasis in 16 or more regional lymph nodes, M0 No distant metastasis, M1 Distant metastasis.Used with the permission of the American College of Surgeons. Amin MB, Edge SB, Greene FL, et al. (Eds.) AJCC Cancer Staging Manual, 8th Ed. Springer New York, 2017.Brunicardi_Ch26_p1099-p1166.indd 114501/03/19 7:12 PM 1146SPECIFIC CONSIDERATIONS PART IIsignificance of the latter has been established by several investigators.156,157 Gastrectomy should be


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Surgery_Schwartz. 114501/03/19 7:12 PM 1146SPECIFIC CONSIDERATIONS PART IIsignificance of the latter has been established by several investigators.156,157 Gastrectomy should be deferred in patients with positive peritoneal cytology without obvious peritoneal metastases. Patients with gastric cancer who undergo R0 resec-tion (i.e., no gross residual disease) and are found to have posi-tive peritoneal cytology (no gross carcinomatosis) have a much poorer prognosis than those with negative cytology (median survival 14.8 months vs. 98.5 months).156 Stand-alone laparos-copy may influence management in up to 36% of cases and is increasingly advocated to allow appropriate initial treatment selection. The yield is likely highest in patients with T3 or T4 tumors, proximal tumors, or evidence of regional nodal involve-ment158; such patients may benefit from neoadjuvant therapy, and laparoscopy should be offered prior to initiation of treat-ment. Systemic therapy is the cornerstone of therapy for patients


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Surgery_Schwartz. involve-ment158; such patients may benefit from neoadjuvant therapy, and laparoscopy should be offered prior to initiation of treat-ment. Systemic therapy is the cornerstone of therapy for patients with Stage IV disease and surgery is generally reserved for pal-liation of symptoms (e.g., an obstructing distal tumor) in patients with metastases identified during laparoscopy.Treatment. Surgical resection is the only potentially curative treatment for gastric cancer,159 and most patients with clini-cally resectable locoregional disease should undergo gastrec-tomy. The goals of curative surgical treatment are resection of all tumor (i.e., R0 resection and adequate lymphadenectomy to afford accurate staging and provide locoregional control. Gener-ally, the surgeon strives for a grossly negative margin of at least 5 cm, although an evidence base for this is lacking and recent retrospective analyses have suggested that more conservative resections may be adequate.160 Conversely, complete


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Surgery_Schwartz. margin of at least 5 cm, although an evidence base for this is lacking and recent retrospective analyses have suggested that more conservative resections may be adequate.160 Conversely, complete resection of diffuse tumors sometimes proves challenging, and wider gross margins guided by frozen section are sometimes appro-priate. Prior to extending the resection on the basis of a positive frozen section margin, the surgeon should determine whether the microscopic tumor cells are within the wall or on the serosal. The latter may indicate incurable disseminated disease, render-ing additional resection proximally or distally moot, particularly when it makes the anastomosis or stump closure more difficult or hazardous.More than 15 resected lymph nodes are required for ade-quate staging, a relevant marker of quality of care.161,162 Thera-peutic nihilism should be avoided, and in the low-risk patient, an aggressive attempt to resect all tumor should be made. The primary tumor may be resected


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Surgery_Schwartz. marker of quality of care.161,162 Thera-peutic nihilism should be avoided, and in the low-risk patient, an aggressive attempt to resect all tumor should be made. The primary tumor may be resected en bloc with adjacent involved organs (e.g., distal pancreas, transverse colon, or spleen) during the course of curative gastrectomy. Palliative gastrectomy may be indicated in the rare patient with incurable disease, but most patients presenting with stage IV gastric cancer can be managed without major operation.163Extent of Gastrectomy The standard operation for gastric cancer is radical subtotal gastrectomy. Unless required for R0 resection, total gastrectomy confers no additional survival ben-efit and may have adverse nutritional or quality-of-life conse-quences and higher perioperative morbidity and mortality.164 Subtotal gastric resection typically entails ligation of the left and right gastric and gastroepiploic arteries at their origins, as well as the en bloc removal of the distal


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Surgery_Schwartz. and mortality.164 Subtotal gastric resection typically entails ligation of the left and right gastric and gastroepiploic arteries at their origins, as well as the en bloc removal of the distal 2/3 of the stomach, includ-ing the pylorus and 2 cm of duodenum, the greater and lesser omentum, and all associated lymphatic tissue (Fig. 26-56). In the absence of involvement by direct extension, the spleen and pancreatic tail are not removed.Reconstruction is usually by Billroth II gastrojejunostomy or Roux-en-Y gastrojejunostomy. The former is associated with shorter operative time and precludes roux limb stasis. The lat-ter mitigates bile reflux and, therefore, may be associated with better quality of life long term. In East Asia, especially Japan, Billroth-I gastroduodenostomy is frequently performed after distal gastrectomy. Billroth-I gastroduodenostomy consists of one anastomosis (which is usually straightforward and keeps the duodenum in the food stream). In the United States,


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Surgery_Schwartz. performed after distal gastrectomy. Billroth-I gastroduodenostomy consists of one anastomosis (which is usually straightforward and keeps the duodenum in the food stream). In the United States, traditional surgical teaching eschews gastroduodenostomy following gas-tric cancer resection because of the possibility of anastomotic recurrence and obstruction. A risk of remnant carcinoma attrib-uted to bile reflux has been invoked in support of Roux-en-Y reconstruction over Billroth II or I. Strong evidence linking reconstruction approach to long-term oncologic outcome is lacking.Total gastrectomy with Roux-en-Y esophagojejunostomy may be required for R0 resection (Fig. 26-57) and is frequently the optimal operation for patients with proximal gastric adeno-carcinoma. The construction of a jejunal pouch is associated with superior nutritional recovery in some but not all reports, and is a consideration.102 Proximal subtotal gastric resection, Gastroepiploicvs.ABDuodenumTransverse


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Surgery_Schwartz. of a jejunal pouch is associated with superior nutritional recovery in some but not all reports, and is a consideration.102 Proximal subtotal gastric resection, Gastroepiploicvs.ABDuodenumTransverse colonTumorLiverStomachStomachJejunumTransverse colonPancreasFigure 26-56. A and B. Radical subtotal gastrectomy. vs. = vessels. (Reproduced with permission from Daly JM, Cady B, Low DW: Atlas of Surgical Oncology. St. Louis, MO: Elsevier/Mosby-Year Book; 1993.)Brunicardi_Ch26_p1099-p1166.indd 114601/03/19 7:13 PM 1147STOMACHCHAPTER 26a technically feasible alternative to total gastrectomy for some proximal gastric tumors, requires esophagogastrostomy to a denervated distal gastric remnant, and functional outcomes are generally poor.165 Pyloroplasty in this setting virtually guar-antees bile esophagitis, and if the pylorus is left intact, gastric emptying may be problematic. An isoperistaltic jejunal intero-sition (Henley loop) between the esophagus and antrum may mitigate some of the


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Surgery_Schwartz. esophagitis, and if the pylorus is left intact, gastric emptying may be problematic. An isoperistaltic jejunal intero-sition (Henley loop) between the esophagus and antrum may mitigate some of the adverse symptoms associated with this operation but adds additional complexity.Extent of Lymphadenectomy The 3rd edition of Japanese classification of gastric carcinoma defines lymph node sta-tions on the basis of anatomic landmarks. Lymph node stations 1 to 12 and 14V are classified as regional and metastasis to any other lymph nodal stations constitute distant disease (M1) (see Fig. 26-4). So-called D1 lymphadenectomy in distal gastrec-tomy requires the dissection of stations 1, 3, 4sb, 4d, 5, 6, and 7. Additional resection of stations 8a, 9, 11p, and 12a constitute D2 lymphadenectomy. D1 lymphadenectomy in total gastrec-tomy requires dissection of stations 1 through 7; D2 lymph-adenectomy includes stations 8a to 12a as well. The operation most commonly performed in the United States for


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Surgery_Schwartz. in total gastrec-tomy requires dissection of stations 1 through 7; D2 lymph-adenectomy includes stations 8a to 12a as well. The operation most commonly performed in the United States for gastric cancer is a D1 resection and involves removal of the primary tumor with perigastric nodes. The standard operation for gastric cancer in Asia and specialized U.S. centers is D2 gastrectomy, which involves a more extensive lymphadenectomy (removal of the D1 and D2 nodes). In addition to the tissue removed in a D1 resection, D2 gastrectomy includes the superior peritoneum overlying the mesocolon and, selectively, the pancreas, as well as nodes along the common hepatic and splenic arteries, and the celiac axis. Splenectomy and distal pancreatectomy are not routinely performed because this has been shown to increase the morbidity and mortality of the operation.166,167The purported survival advantage of D2 gastrectomy in gastric cancer is illustrated in Table 26-20, which shows the 5-year survival


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Surgery_Schwartz. to increase the morbidity and mortality of the operation.166,167The purported survival advantage of D2 gastrectomy in gastric cancer is illustrated in Table 26-20, which shows the 5-year survival rates for gastric cancer stratified by pathologic stage for the United States and Japan. Randomized prospective trials have not confirmed this survival advantage. Two stud-ies showed increased operative mortality with D2 gastrectomy, but the most recent study did not (Table 26-21).166,168,169 With extended lymphadenectomy, much of the morbidity and mor-tality is attributable to performance of splenectomy and distal pancreatectomy, which are no longer routinely included as part of the D2 gastrectomy. Because D2 lymphadenectomy in total gastrectomy requires the dissection of station 10 (i.e., splenic hilar lymph nodes) splenectomy is still selectively performed, particularly for locally advanced fundic tumors.Longer-term follow-up from the Dutch lymphdenectomy trial demonstrating a


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Surgery_Schwartz. (i.e., splenic hilar lymph nodes) splenectomy is still selectively performed, particularly for locally advanced fundic tumors.Longer-term follow-up from the Dutch lymphdenectomy trial demonstrating a disease-specific survival advantage with D2 dissection170 as well as recognition that pancreas and spleen preserving dissection can be performed with low morbidity169 have provided momentum for increased utilization of D2 gas-trectomy at high-volume centers in the United States and Europe. Some experts have argued that the D2 operation affords better staging and informs more rational decision-making regarding multimodality therapy. Without question, D2 provides a bet-ter yield of evaluable nodes. Given the frequent inadequacy of lymph node evaluation with gastrectomy in the United States and the association with poorer outcomes, greater attention to the conduct of the operation and pathologic specimen evaluation is clearly desirable. Whether better outcomes after more exten-sive


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Surgery_Schwartz. and the association with poorer outcomes, greater attention to the conduct of the operation and pathologic specimen evaluation is clearly desirable. Whether better outcomes after more exten-sive dissection are an epiphenomenon of improved pathologic staging, or a function of therapeutic benefit, remains unclear.Chemotherapy and Radiation for Gastric Cancer The actu-arial 5-year survival rates for resected gastric adenocarcinoma stages I, II, and III in the United States are approximately 75%, 50%, and 25%, respectively. Because most surgical patients have stage II disease or greater, adjuvant therapy is indicated in the majority of patients who undergo initial resection. Adjuvant chemotherapy alone has not proven effective, at least in studies from Europe and the United States.171 Several studies from Table 26-20Gastric cancer 5-year survival and operative mortality in the United States and Japan MARUYAMA (JAPAN), 1971–1985AMERICAN COLLEGE OF SURGEONS, 1982–1987MEMORIAL SLOAN


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Surgery_Schwartz. Several studies from Table 26-20Gastric cancer 5-year survival and operative mortality in the United States and Japan MARUYAMA (JAPAN), 1971–1985AMERICAN COLLEGE OF SURGEONS, 1982–1987MEMORIAL SLOAN KETTERING, 1985–1994No. patients317618,365675Stage I91%50%84%Stage II72%29%61%Stage III44%13%29%Stage IV9%3%25%Operative mortality1%7%3%60 cmFigure 26-57. Reconstruction after total gastrectomy. Jejunal pouch (not shown here) should be considered. (Reproduced with permission from Zinner MJ: Atlas of Gastric Surgery. New York, NY: Elsevier/Churchill Livingstone; 1992.)Brunicardi_Ch26_p1099-p1166.indd 114701/03/19 7:13 PM 1148SPECIFIC CONSIDERATIONS PART IIJapan and Korea have indicated a survival advantage with adju-vant chemotherapy after D2 gastrectomy.172-174 The discordance between outcomes in Asia and those from the United States and Europe have been attributed to differences in disease biology or treatment approaches. Proponents of the latter suggest that D2 lymphadenectomy


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Surgery_Schwartz. outcomes in Asia and those from the United States and Europe have been attributed to differences in disease biology or treatment approaches. Proponents of the latter suggest that D2 lymphadenectomy provides sufficient locoregional control and that chemotherapy alone has efficacy after optimal surgery. A preferred adjuvant approach in the United States incorpo-rates chemotherapy and radiation based on the results of the Intergroup trial. This prospective randomized study of adju-vant treatment with chemotherapy (5-fluorouracil and leucovo-rin) and radiation (4500 cGy) demonstrated a survival benefit in resected patients with stage II and III adenocarcinoma of the stomach.175 Only 10% of patients entered in the study actually had D2 gastrectomy, and most (54%) had less than an adequate D1 gastrectomy. Because adequacy of lymphadenectomy has been correlated with survival, particularly in patients with stage III gastric cancer, it has been suggested that the benefits of adjuvant


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Surgery_Schwartz. D1 gastrectomy. Because adequacy of lymphadenectomy has been correlated with survival, particularly in patients with stage III gastric cancer, it has been suggested that the benefits of adjuvant chemoradiation shown in this study would be vitiated by a more extensive operation.Neoadjuvant chemotherapy has emerged as a viable alter-native to adjuvant chemoradiotherapy in Europe and the United States. Theoretical advantages of this approach include more consistent completion of multimodality therapy, downstaging, earlier treatment of micrometastatic disease, and the ability to gauge response at the in situ tumor. The MAGIC trial, a random-ized controlled trial comparing perioperative epirubicin, cispla-tin, and 5-flourouracil to surgery alone demonstrated a survival advantage and supported this approach in patients with at least stage II disease.176 A subset of patients with very symptomatic tumors may not be eligible for this approach, and the perception that systemic therapy is an


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Surgery_Schwartz. this approach in patients with at least stage II disease.176 A subset of patients with very symptomatic tumors may not be eligible for this approach, and the perception that systemic therapy is an ineffective detour for patients who require locoregional control with surgery is sometimes hard to overcome. Regardless, neoadjuvant approaches are increasingly utilized, and even more rigorous regimens incorporating radio-therapy or targeted agents have been explored, sometimes with promising outcomes.177Recent clinical trials from Asia suggest the potential ben-efit of adjuvant chemotherapy after D2 lymphadenectomy in patients with advanced gastric cancer. These trials compared surgery alone and surgery plus adjuvant chemotherapy including oral fluoropyrimidines in resected advanced gastric cancer.172,173 A study from the Japan Clinical Oncology Group showed a 69% overall 5-year survival rate in patients with clinically curable T2b, T3, and T4 gastric cancer, treated with D2 gastrectomy


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Surgery_Schwartz. cancer.172,173 A study from the Japan Clinical Oncology Group showed a 69% overall 5-year survival rate in patients with clinically curable T2b, T3, and T4 gastric cancer, treated with D2 gastrectomy alone.178 A subsequent trial from Korea demonstrated a survival advantage with adjuvant capecitabine and oxaliplatin after D2 gastrectomy compared to D2 gastrectomy alone.173 It is uncer-tain whether this approach can be translated to patients in the United States.Although the prognosis of metastatic or recurrent gastric cancer is poor, systemic chemotherapy provides a significant survival benefit over the best supportive care.179,180 Agents that have shown activity against gastric cancer include 5-fluorouracil (5-FU), cisplatin, doxorubicin, methotrexate, taxanes, and camptothecin. Until recently, 5-FU–based chemotherapy, especially in combination with platinums, played a key role in the treatment for the unresectable gastric cancer as well as several types of cancer, such as colon and


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Surgery_Schwartz. 5-FU–based chemotherapy, especially in combination with platinums, played a key role in the treatment for the unresectable gastric cancer as well as several types of cancer, such as colon and lung. In the 1990s, the introduction of novel anticancer agents such as camptoth-ecin, taxanes, third-generation platinums, and new oral fluo-ropyrimidines, improved the prognosis of unresectable gastric cancer.179,180It is likely that targeted molecular agents will have an increasing role in treating gastric cancer. Recently, Trastu-zumab, a humanized molecular antibody reactive against the extracellular domain of HER2, increased the effectiveness of cytotoxic chemotherapy in patients with HER2 over-expressing advanced gastric cancer.152 Other large trials are ongoing. Deter-mination of HER2 gene amplification status may have prognos-tic significance.181Endoscopic Resection182 The shortand long-term morbidity associated with gastrectomy and the relatively infrequent dis-semination of superficial


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Surgery_Schwartz. status may have prognos-tic significance.181Endoscopic Resection182 The shortand long-term morbidity associated with gastrectomy and the relatively infrequent dis-semination of superficial (i.e., T1) tumors to regional nodes have compelled exploration of endoscopic resection for selected lesions. Numerous East Asian centers have demonstrated that some patients with early gastric cancer are adequately treated with endoscopic mucosal resection (EMR). EMR is most appro-priate for patients in whom the probability of lymph node metas-tasis is low. According to the Japanese treatment guidelines for gastric cancer, EMR is a standard treatment for well differenti-ated gastric cancer confined to the mucosa (T1a), measuring less than 2 cm and without signs of ulceration. Such lesions are associated with a negligible risk of lymph node metastasis. 6Table 26-21Randomized trials comparing D1 and D2 gastrectomy for gastric cancerAUTHORSNUMBER OF PATIENTSTYPE OF SURGERYPOSTOPERATIVE


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Surgery_Schwartz. are associated with a negligible risk of lymph node metastasis. 6Table 26-21Randomized trials comparing D1 and D2 gastrectomy for gastric cancerAUTHORSNUMBER OF PATIENTSTYPE OF SURGERYPOSTOPERATIVE COMPLICATIONSPOSTOPERATIVE MORTALITY5 YEAR SURVIVALBonenkamp et al.711D125445 D2431047Cuschieri et al.400D1286.535 D2461333Degiuli et al.267D1123 D217.92.2 Data from Bonenkamp JJ, Hermans J, Sasako M, et al. Extended lymph node dissection for gastric cancer. N Engl J Med. 1999;340:908; Cuschieri A, Fayers P, Fielding J, et al. Postoperative morbidity and mortality after D1 and D2 resections for gastric cancer: preliminary results of the MRC randomized controlled surgical trial. The Surgical Cooperative Group. Lancet. 1996;347:995; and Degiuli M, Sasako M, Ponti A, et al. Morbidity and mortality in the Italian Gastric Cancer Study Group randomized clinical trial of D1 versus D2 resection for gastric cancer. Br J Surg. 2010;97:5.Brunicardi_Ch26_p1099-p1166.indd 114801/03/19 7:13 PM


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Surgery_Schwartz. in the Italian Gastric Cancer Study Group randomized clinical trial of D1 versus D2 resection for gastric cancer. Br J Surg. 2010;97:5.Brunicardi_Ch26_p1099-p1166.indd 114801/03/19 7:13 PM 1149STOMACHCHAPTER 26En bloc resection is required to evaluate margins for confirma-tion of complete resection. The development of endoscopic submucosal dissection (ESD) allows en bloc resection of larger tumors. This has increased the feasibility of endoscopic resec-tion of larger lesions (<3 cm) at experienced centers. If patho-logic evaluation of the resected specimen does not demonstrate ulceration, penetration of the muscularis mucosae, or lymphatic invasion, the risk of lymph node metastases is less than 1%. Even the occasional patient with higher risk stigmata may be managed endoscopically, particularly in the presence of comor-bidities that preclude safe operation.Screening for Gastric Cancer. In Japan, it clearly has been shown that patients participating in gastric cancer screening


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Surgery_Schwartz. particularly in the presence of comor-bidities that preclude safe operation.Screening for Gastric Cancer. In Japan, it clearly has been shown that patients participating in gastric cancer screening pro-grams have a significantly decreased risk of dying from gastric cancer. Thus, screening is effective in a high-risk population. Screening the general population in the United States (a low-risk country) is probably not justified, but patients clearly at risk for gastric cancer probably should have periodic endoscopy and biopsy. This includes patients with familial adenomatous polyposis, hereditary nonpolyposis colorectal cancer, gastric adenomas, Ménétrier’s disease, intestinal metaplasia or dyspla-sia, and remote gastrectomy or gastrojejunostomy.Gastric LymphomaGastric lymphomas generally account for about 4% of gastric malignancies. Over half of patients with non-Hodgkin’s lym-phoma have involvement of the GI tract. The stomach is the most common site of primary GI lymphoma, and over


Surgery_Schwartz

Surgery_Schwartz. account for about 4% of gastric malignancies. Over half of patients with non-Hodgkin’s lym-phoma have involvement of the GI tract. The stomach is the most common site of primary GI lymphoma, and over 95% are non-Hodgkin’s type. Most are B-cell type, thought to arise in mucosa associated lymphoid tissue (MALT), although most high-grade gastric lymphomas are without any characteristics of the low-grade MALT neoplasm.183 About half of gastric lym-phomas are histologically low grade, and about half are high grade. Interestingly, the normal stomach is relatively devoid of lymphoid tissue. However, in the setting of chronic gastritis, the stomach acquires MALT, which can undergo malignant degen-eration. Again, H pylori is thought to be the culprit. In popula-tions with a high incidence of gastric lymphoma, there is a high incidence of H pylori infection; patients with gastric lymphoma also usually have H pylori infection.184Low-grade MALT lymphoma, essentially a monoclonal proliferation of


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Surgery_Schwartz. lymphoma, there is a high incidence of H pylori infection; patients with gastric lymphoma also usually have H pylori infection.184Low-grade MALT lymphoma, essentially a monoclonal proliferation of B cells, presumably arises from a background of chronic gastritis associated with H pylori. These relatively innocuous tumors then undergo degeneration to high-grade lymphoma, which is the usual variety seen by the surgeon. Remarkably, when the H pylori is eradicated and the gastritis improves, the low-grade MALT lymphoma often disappears. Thus, low-grade MALT lymphoma is not a surgical lesion. Careful follow-up is necessary particularly in those lesions with a t(11:18) translocation, thought to be a risk factor for a more aggressive MALT lesion. If low-grade lymphoma per-sists after H pylori eradication, radiation should be consid-ered for disease clinically confined to the stomach (stage I), while chemotherapy with or without radiation is used for more advanced lesions (Fig.


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Surgery_Schwartz. H pylori eradication, radiation should be consid-ered for disease clinically confined to the stomach (stage I), while chemotherapy with or without radiation is used for more advanced lesions (Fig. 26-58).Patients with high-grade gastric lymphoma require aggres-sive oncologic treatment for cure and present with many of the same symptoms as gastric cancer patients. However, systemic symptoms such as fever, weight loss, and night sweats occur in about 50% of patients with gastric lymphoma. The tumors may bleed and/or obstruct. Lymphadenopathy and/or organomegaly suggest systemic disease. Diagnosis is by endoscopy and biopsy. Much of the tumor may be submucosal, and an assiduous attempt at biopsy is necessary. Primary lymphoma is usually nodular with enlarged gastric folds. A diffusely infiltrative pro-cess akin to linitis plastica is more suggestive of secondary gas-tric involvement by lymphoma. A diligent search for extragastric disease is necessary before the diagnosis of localized


Surgery_Schwartz

Surgery_Schwartz. pro-cess akin to linitis plastica is more suggestive of secondary gas-tric involvement by lymphoma. A diligent search for extragastric disease is necessary before the diagnosis of localized primary gastric lymphoma is made. This includes EUS; CT scanning of the chest, abdomen, and pelvis; and bone marrow biopsy. Most patients with high-grade gastric lymphoma are currently treated with chemotherapy and radiation, without surgical resection. Treatment-related perforation or bleeding is an unusual but recognized complication. For disease limited to the stomach and regional nodes, radical subtotal D2 gastrectomy may be performed, especially for bulky tumors with bleeding and/or obstruction. Palliative gastrectomy for tumor complica-tions also has a role. Certainly, a multidisciplinary team should be involved in managing patients with primary gastric lymphoma.Gastrointestinal Stromal TumorGISTs arise from interstitial cells of Cajal (ICC) and are dis-tinct from leiomyoma and


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Surgery_Schwartz. team should be involved in managing patients with primary gastric lymphoma.Gastrointestinal Stromal TumorGISTs arise from interstitial cells of Cajal (ICC) and are dis-tinct from leiomyoma and leiomyosarcoma, which arise from smooth muscle.185,186 Prognosis in patients with GIST tumors depends on tumor size, location, and mitotic count. Metasta-sis, when it occurs, is typically by the hematogenous route. Virtually all GISTs should be resected along with a margin of normal tissue. Most GISTs (and almost no smooth muscle tumors) express c-KIT (CD117) or the related PDGF receptor A, as well as CD34; almost all smooth muscle tumors (and almost no GISTs) express actin and desmin. These markers can often be detected on specimens obtained by fine-needle aspiration187 and are useful in differentiating between GIST and smooth muscle tumor histopathologically. Lesions that are definitively leiomyoma by histopathologic criteria can be observed if small and asymptomatic. Larger or symptomatic


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Surgery_Schwartz. between GIST and smooth muscle tumor histopathologically. Lesions that are definitively leiomyoma by histopathologic criteria can be observed if small and asymptomatic. Larger or symptomatic gastric leiomyomas are adequately treated by enucleation or wedge resection. Lesions that are definitively GIST or leio-myosarcoma are best treated by resection with negative mar-gins. Most equivocal lesions should be resected provided that the patient has a reasonable operative risk.Two-thirds of all GISTs occur in the stomach and have a more favorable prognosis than do GISTs occurring in other locations. Epithelial cell stromal GIST is the most common cell type arising in the stomach, and cellular spindle type is the next most common. The glomus tumor type is seen only in the stom-ach. Smaller lesions are usually found incidentally, although they occasionally may ulcerate and cause bleeding. Larger lesions may produce symptoms of weight loss, abdominal pain, fullness, early satiety, and


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Surgery_Schwartz. lesions are usually found incidentally, although they occasionally may ulcerate and cause bleeding. Larger lesions may produce symptoms of weight loss, abdominal pain, fullness, early satiety, and bleeding. An abdominal mass may be palpable. Metastasis is by the hematogenous route, most often to liver.Diagnosis is by endoscopy and biopsy, although the inter-pretation of the latter may be problematic. When performed, a transluminal (i.e., endoscopic) approach to biopsy is preferred to a percutaneous one, to avoid to the potential for fragmenta-tion and peritoneal seeding. A nondiagnostic biopsy does not preclude resection of a suspicious appearing lesion. Metastatic workup entails CT of the abdomen, and pelvis (chest X-ray suf-fices in lieu of CT of the chest for most patients). Most GISTs are solitary. Local resection with clear margins is adequate sur-gical treatment but is sometimes impractical for larger prepy-loric or pyloric channel tumors, or those near the GE junction.


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Surgery_Schwartz. GISTs are solitary. Local resection with clear margins is adequate sur-gical treatment but is sometimes impractical for larger prepy-loric or pyloric channel tumors, or those near the GE junction. 7Brunicardi_Ch26_p1099-p1166.indd 114901/03/19 7:13 PM 1150SPECIFIC CONSIDERATIONS PART IITrue invasion of adjacent structures by the primary tumor is occasionally seen with larger more aggressive lesions. If safe, en bloc resection of involved surrounding organs is appropriate to remove all tumor.The risk of tumor recurrence or metastasis behavior has been stratified into four groups according to the tumor size and mitotic count.110 Very low risk is defined by size <2 cm and <5 mitoses/50 HPF (high-power field). Low risk is defined by size 2 to 5 cm and <5 mitoses/50 cm. Intermediate risk is defined by size <5 cm and 6 to 10 mitoses/50 HPF or size 5 to 10 cm and >5 mitoses/50 HPF. High risk is defined by size >5 cm and >5 mitoses/50HPF, size >10 cm regardless of mitotic rate or >10


Surgery_Schwartz

Surgery_Schwartz. is defined by size <5 cm and 6 to 10 mitoses/50 HPF or size 5 to 10 cm and >5 mitoses/50 HPF. High risk is defined by size >5 cm and >5 mitoses/50HPF, size >10 cm regardless of mitotic rate or >10 mitoses/50 HPF regardless of size. As mentioned, stomach lesions are associated with lower risk than are tumors in other locations. Classification based on tumor location, size, and mitotic rate have been proposed to evaluate the risk of recurrence and metastasis and role for adjuvant therapy.188 In an effort to further refine risk stratification, a number of nomo-grams have been introduced incorporating tumor features. These tools draw upon and are subject to the limitations of the institu-tional data from which they are derived, but they are sometimes helpful in counseling patients.Mutations in the oncodriver c-kit and PDGFRA are pres-ent in a majority of GISTs. This has been exploited through the use of imatinib (Gleevec), a tyrosine kinase inhibitor. Sev-eral clinical trials in a


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Surgery_Schwartz. in the oncodriver c-kit and PDGFRA are pres-ent in a majority of GISTs. This has been exploited through the use of imatinib (Gleevec), a tyrosine kinase inhibitor. Sev-eral clinical trials in a metastatic disease setting demonstrated marked improvements in median survival from 9 months to greater than 5 years.189 These striking results not only estab-lished imatinib as the primary therapy for metastatic GIST, but they also compelled broader efforts to target solid tumors with small molecule inhibitors. Notably, up to 50% of treated patients develop resistance to imatinib by 2 years, and several Low-grade (indolent) MALTLymphoma persistsStage IIChemo** + XRT*Stage IXRT**XRT: external beam radiation therapy, approximately 30 Gy with 10 Gy boost**Chemo: chemotherapy regimens include chlorambucil, fludarabinel,and cyclosphosphamide, vincristine, prednisone (COP) +/– rituximabClose follow-upNo residual diseaseResidual diseaseFurther chemotherapy*Chemo: chemotherapy regimen usually


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Surgery_Schwartz. chlorambucil, fludarabinel,and cyclosphosphamide, vincristine, prednisone (COP) +/– rituximabClose follow-upNo residual diseaseResidual diseaseFurther chemotherapy*Chemo: chemotherapy regimen usually cyclophosphamide,doxorobicin, vincristine, prednisone (CHOP) +/– rituximab**XRT: external beam radiation, approximately 30 Gy with 10 Gy boostFollow-upLymphoma regressionHigh-grade (aggressive)SurgeryStage IVChemo* +/– XRT**Stage I, II, IIIChemo* + XRT**Stage III or IVLymph node involvementt(11:18) translocationConfined to gastric wallNo t(11:18) translocationH pylori eradication therapyand chemo** +/– XRT*H pylori eradication therapyRe-evaluate at 3–6 monthsH pylori eradication therapyRe-evaluate at 12 monthsFigure 26-58. Algorithm for the treatment of gastric lymphoma. MALT = mucosa-associated lymphoid tissue. (Reproduced with permission from Yoon SS, Coit DG, Portlock CS, et al. The diminishing role of surgery in the treatment of gastric lymphoma, Ann Surg. 2004


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Surgery_Schwartz. MALT = mucosa-associated lymphoid tissue. (Reproduced with permission from Yoon SS, Coit DG, Portlock CS, et al. The diminishing role of surgery in the treatment of gastric lymphoma, Ann Surg. 2004 Jul;240(1):28-37.)Brunicardi_Ch26_p1099-p1166.indd 115001/03/19 7:13 PM 1151STOMACHCHAPTER 26second-line agents have been utilized for patients with refrac-tory disease, most notable sunitinib.The efficacy of imatinib as adjuvant therapy for high risk GIST has been demonstrated in two randomized clinical trials, ACOSOG Z9001 and SSG XVIII.190,191 The former trial randomized patients to 1 year of adjuvant imatinib or pla-cebo and showed an improvement in recurrence-free survival with imatinib. The latter trial demonstrated an overall survival advantage with 3 years compared to 1 year of therapy. Imatinib is now recommended in high risk groups as an adjuvant therapy, for three years or longer. Preoperative therapy with imatinib may be indicated in selected patients with larger lesions


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Surgery_Schwartz. Imatinib is now recommended in high risk groups as an adjuvant therapy, for three years or longer. Preoperative therapy with imatinib may be indicated in selected patients with larger lesions that may be more difficult to completely resect or require multivis-ceral resection.Molecular profiling has been embraced with growing rec-ognition that specific tumor subtypes are insensitive to imatinib. Patients with PDGFRA D842V mutations, for example, do not respond to imatinib.192 Management of metastatic GIST is prin-cipally medical, but surgery has a selected role. An algorithm for the treatment of patients with metastatic GIST is shown in Fig. 26-59.Gastric Neuroendocrine Tumors193,194Compared to neuroendocrine tumors of the midgut and hind-gut, neuroendcorine tumors of the stomach are rare. Gastric neuroendocrine tumors comprise about 1% of all neuroen-docrine tumors and less than 2% of gastric neoplasms. They arise from gastric enterochromaffin-like (ECL) cells and may have malignant


Surgery_Schwartz

Surgery_Schwartz. Gastric neuroendocrine tumors comprise about 1% of all neuroen-docrine tumors and less than 2% of gastric neoplasms. They arise from gastric enterochromaffin-like (ECL) cells and may have malignant potential. The apparent incidence of gastric neuroendocrine tumors is increasing, perhaps related to increased detection or the increasing use of acid suppres-sive medication. The latter may cause hypergastrinemia, and gastrin has a recognized trophic effect on gastric ECL cells. Nomenclature remains a point of confusion; carcinoid and well-differentiated neuroendocrine tumor (NET) are synony-mous according to WHO classification.Gastric neuroendocrine tumors are classified into one of three different types. Type I is the most common, account-ing for about 75% of cases. Type I lesions occur in patients with chronic hypergastrinemia secondary to pernicious anemia or atrophic gastritis. These lesions occur more frequently in women, are often multiple and small, and have low malignant potential


Surgery_Schwartz

Surgery_Schwartz. with chronic hypergastrinemia secondary to pernicious anemia or atrophic gastritis. These lesions occur more frequently in women, are often multiple and small, and have low malignant potential (<5% metastasize). The role of long-term acid sup-pression with resultant hypergastrinemia in the pathogenesis of type I gastric carcinoids is unclear. Type II gastric neuroendo-crine tumors are associated with MEN1 and ZES. These lesions also tend to be small and multiple, but they have a somewhat higher malignant potential than type I lesions (10% metasta-size). Type II lesions are more common in the setting of MEN1; they are quite uncommon in patients with sporadic ZES. The constellation of gastric acidity, hypergastrinemia, and gastric neuroendocrine tumors suggests gastrinoma until proven other-wise. Type III gastric neuroendocrine tumors are sporadic. They are most often solitary (usually >2 cm) and occur more com-monly in men. They are not associated with hypergastrinemia. Most patients


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Surgery_Schwartz. Type III gastric neuroendocrine tumors are sporadic. They are most often solitary (usually >2 cm) and occur more com-monly in men. They are not associated with hypergastrinemia. Most patients have regional nodal or distant metastases at the time of diagnosis, and some present with symptoms of carcinoid syndrome.Gastric neuroendocrine tumors are usually diagnosed with endoscopy and biopsy. The type can be determined based upon clinical context, patient history, the presence or absence of atro-phic gastric mucosa, gastric pH and gastrin level. Some tumors are submucosal and may be quite small. They are often confused with heterotopic pancreas or small leiomyomas. Biopsy may be difficult because of the submucosal location, and EUS can be helpful in defining the size and depth of the lesion. Plasma 8Metastatic or recurrent GISTRepeat imaging in 1 to 3 monthsResponsive/Stable diseaseResectableConsidersurgeryContinueimatinibUnresectableConsidersurgeryDose escalation toimatinib 400 mg


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Surgery_Schwartz. Plasma 8Metastatic or recurrent GISTRepeat imaging in 1 to 3 monthsResponsive/Stable diseaseResectableConsidersurgeryContinueimatinibUnresectableConsidersurgeryDose escalation toimatinib 400 mg bidSunitinibRegorafenibClinical trialUnifocalMultifocalProgressive diseaseImatinib 400 mg four times a day in all KIT, non-D842V PDGFRA mutations,and WT GIST Consider 400 mg twice a day in exon 9 KIT mutationsConsider clinical trial in PDGFRA D842V mutationsFigure 26-59. Algorithm for the treatment of malignant gastrointestinal stromal tumor. (Reproduced with permission from Balachandran VP, DeMatteo RP: Gastrointestinal stromal tumors: who should get imatinib and for how long? Adv Surg. 2014;48:165-183.)Brunicardi_Ch26_p1099-p1166.indd 115101/03/19 7:13 PM 1152SPECIFIC CONSIDERATIONS PART IIchromogranin A levels are frequently elevated. CT scan and octreotide or gallium dotatate scans are useful for staging.Type I and II patients with numerous diminutive lesions can be followed with


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Surgery_Schwartz. A levels are frequently elevated. CT scan and octreotide or gallium dotatate scans are useful for staging.Type I and II patients with numerous diminutive lesions can be followed with serial endoscopy. Small lesions con-fined to the mucosa (typically type I or type II lesions) less than 1 cm may be treated endoscopically with EMR if there are only a few lesions (<5). Occasionally a slightly larger lesion (1–2 cm) necessitate local surgical excision. Larger lesions and type III lesions should be removed by D1 or D2 gastrectomy. Antrectomy to mitigate gastric secretion in type I patients with refractory growing lesions was invoked as a viable treatment strategy in the past, but it is rarely indicated.Survival is excellent for node-negative patients (>90% 5-year survival); node-positive patients have a 50% 5-year sur-vival. Gastrinoma should be resected if located in patients with type II carcinoid. The 5-year survival for patients with type I gastric carcinoid is close to 100%; for


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Surgery_Schwartz. patients have a 50% 5-year sur-vival. Gastrinoma should be resected if located in patients with type II carcinoid. The 5-year survival for patients with type I gastric carcinoid is close to 100%; for patients with type III lesions, the 5-year survival is less than 50%. Somatostatin ana-logue therapy may delay progression of metastatic disease. Sur-gical debulking may have a role in selected patients with limited metastatic disease.BENIGN GASTRIC NEOPLASMSLeiomyomaThe typical leiomyoma is submucosal and firm. If ulcerated, it has an umbilicated appearance and may bleed. Histologically, these lesions appear to be of smooth muscle origin. Lesions <2 cm are usually asymptomatic and benign. Larger lesions may cause symptoms such as bleeding, obstruction, or pain. Asymp-tomatic lesions <2 cm may be carefully observed or enucleated if fine-needle aspiration and immune markers confirm smooth muscle tumor; larger lesions and symptomatic lesions should be removed by wedge resection (often


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Surgery_Schwartz. cm may be carefully observed or enucleated if fine-needle aspiration and immune markers confirm smooth muscle tumor; larger lesions and symptomatic lesions should be removed by wedge resection (often possible laparoscopically). When lesions thought to be leiomyoma are observed rather than resected, the patient should be made aware of their presence and the small possibility for malignancy.LipomaLipomas are benign submucosal fatty tumors that are usually asymptomatic, found incidentally on upper GI series or EGD. Endoscopically, they have a characteristic appearance; there also is a characteristic appearance on EUS. Excision is unnec-essary unless the patient is symptomatic.GastroparesisGastric motility disorders include delayed gastric emptying (gastroparesis), rapid gastric emptying, and motor and sensory abnormalities (e.g., functional dyspepsia). Surgically relevant secondary disorders of gastric motility (e.g., dumping, gastric stasis, and Roux syndrome) are discussed under


Surgery_Schwartz

Surgery_Schwartz. and motor and sensory abnormalities (e.g., functional dyspepsia). Surgically relevant secondary disorders of gastric motility (e.g., dumping, gastric stasis, and Roux syndrome) are discussed under Postgastrec-tomy Problems. Gastroparesis is the most surgically relevant primary disorder of gastric motility.195,196Most patients with primary gastroparesis present with nausea, vomiting, bloating, early satiety, and/or abdominal pain. Eighty percent of these patients are women; some are diabetic. Postprandial vomiting significantly complicates the management of blood glucose in the latter group, predispos-ing to hypoglycemia following preprandial insulin. In patients with gastroparesis, it is important to rule out mechanical gastric outlet obstruction, and small-bowel obstruction. An upper GI series may suggest slow gastric emptying and relative atony, 9or it may be normal. EGD may show bezoars or retained food but is frequently normal. Gastric emptying scintigraphy shows delayed solid


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Surgery_Schwartz. GI series may suggest slow gastric emptying and relative atony, 9or it may be normal. EGD may show bezoars or retained food but is frequently normal. Gastric emptying scintigraphy shows delayed solid emptying, and often delayed liquid emptying. Gastroparesis can be a manifestation of a variety of problems (Table 26-22). Medical treatment includes promotility agents, antiemetics, and, perhaps, botulinum injection into the pylorus.If the diabetic gastroparetic patient is not a candidate for pancreas transplant, both gastrostomy (for decompression) and jejunostomy tubes (for feeding and prevention of hypo-glycemia) can be helpful in managing these patients. Other surgical options include implantation of a gastric pacemaker, pyloroplasty or peroral endoscopic pyloromyotmy (particularly in patients responsive to pyloric Botox injection), and gastric resection.197 Generally, gastric resection should be done only after other therapeutic options have been exhausted.Massive Upper


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Surgery_Schwartz. in patients responsive to pyloric Botox injection), and gastric resection.197 Generally, gastric resection should be done only after other therapeutic options have been exhausted.Massive Upper Gastrointestinal BleedingAlthough there are arbitrary definitions of “massive” upper GI bleeding put forth, perhaps the most practical definition in the current era would be acute GI bleeding proximal to the ligament of Treitz, which requires blood transfusion. In multiple series, the stomach and proximal duodenum are by far the most com-mon sources of pathology associated with this diagnosis.109,198 Table 26-22Etiology of gastroparesisIdiopathicEndocrine or metabolic Diabetes mellitus Thyroid disease Renal insufficiencyAfter gastric surgery After resection After vagotomyCentral nervous system disorders Brain stem lesions Parkinson’s diseasePeripheral neuromuscular disorders Myotonia dystrophica Duchenne muscular dystrophyConnective tissue


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Surgery_Schwartz. resection After vagotomyCentral nervous system disorders Brain stem lesions Parkinson’s diseasePeripheral neuromuscular disorders Myotonia dystrophica Duchenne muscular dystrophyConnective tissue disorders Scleroderma Polymyositis/dermatomyositisInfiltrative disorders Lymphoma AmyloidosisDiffuse gastrointestinal motility disorder Chronic intestinal pseudo-obstructionMedication-inducedElectrolyte imbalance Potassium, calcium, magnesiumMiscellaneous conditions Infections (especially viral) Paraneoplastic syndrome Ischemic conditions Gastric ulcerReproduced with permission from Parkman HP, Harris AD, Krevsky B, et al: Gastroduodenal motility and dysmotility: an update on techniques available for evaluation, Am J Gastroenterol. 1995 Jun;90(6):869-892.Brunicardi_Ch26_p1099-p1166.indd 115201/03/19 7:13 PM 1153STOMACHCHAPTER 26The most common causes of acute upper GI bleeding in emer-gency department or hospitalized patients are peptic ulcer, gastri-tis, Mallory-Weiss syndrome, and


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Surgery_Schwartz. 7:13 PM 1153STOMACHCHAPTER 26The most common causes of acute upper GI bleeding in emer-gency department or hospitalized patients are peptic ulcer, gastri-tis, Mallory-Weiss syndrome, and esophagogastric varices. Less common causes include benign or malignant neoplasm, angio-dysplasia, Dieulafoy’s lesion, portal gastropathy, Ménétrier’s disease, and watermelon stomach. Arterioenteric fistula should always be considered in the patient who has an aortic graft or who has undergone repair of a visceral artery aneurysm.The most important issues in the early hospital manage-ment of patients with acute upper GI bleeding are resuscita-tion and risk stratification. Large-bore IV access and Foley catheterization is accomplished, and nasogastric intubation is considered. Risk stratification is essentially accomplished by answering the following questions:a. What is the magnitude and acuity of the hemorrhage? Hy-potension, tachycardia, oliguria, low hematocrit, pallor, al-tered mentation, and/or


Surgery_Schwartz

Surgery_Schwartz. accomplished by answering the following questions:a. What is the magnitude and acuity of the hemorrhage? Hy-potension, tachycardia, oliguria, low hematocrit, pallor, al-tered mentation, and/or hematemesis suggest a large blood loss that has occurred over a short period of time. This is a high-risk situation.b. Does the patient have significant chronic disease, particu-larly lung, liver, kidney, and/or heart disease, which com-promises physiologic reserve? If yes, this is a high-risk situation.c. Is the patient anticoagulated, or immunosuppressed? If yes, this is a high-risk situation.d. On endoscopy, is the patient bleeding from varices, or is there active bleeding, or is there a visible vessel, or is there a deep ulcer overlying a large vessel (e.g., posterior duode-nal ulcer overlying the gastroduodenal artery)? Could the patient be bleeding from an arterio-enteric fistula? If yes, this is a high-risk situation.When judged to be low risk, most patients will stop bleed-ing with


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Surgery_Schwartz. the gastroduodenal artery)? Could the patient be bleeding from an arterio-enteric fistula? If yes, this is a high-risk situation.When judged to be low risk, most patients will stop bleed-ing with supportive treatment and IV PPI. Selected patients may be discharged from the emergency department and managed on an outpatient basis.If the patient is deemed to be high risk based on one or more of the aforementioned questions, then the following should be done immediately:1. Type and cross-match for transfusion of blood products.2. Admit to ICU or monitored bed in specialized unit.3. Consult surgeon.4. Consult gastroenterologist.5. Start intravenous PPI.6. Perform upper endoscopy within 12 hours, after resuscita-tion and correction of coagulopathy. Endoscopic hemosta-sis should be considered in most high-risk patients with acute upper GI bleeding.Although the surgeon should be involved early in the hos-pital course of all high-risk patients with acute upper GI bleed-ing, most of these


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Surgery_Schwartz. in most high-risk patients with acute upper GI bleeding.Although the surgeon should be involved early in the hos-pital course of all high-risk patients with acute upper GI bleed-ing, most of these patients will be adequately managed without operation. Mucosal lesions can usually be controlled with endo-scopic hemotherapy and medical management. Occasionally, arteriography can be helpful.199 Operation for bleeding ulcer is discussed previously (see “Operation for Bleeding Peptic Ulcer” and Fig. 26-43).Isolated Gastric VaricesIsolated gastric varices are those that occur in the absence of esophageal varices and are classified as type I (fundic) or type II (distal to fundus including proximal duodenum).200 The presence of isolated gastric varices is usually associated with portal hyper-tension or splenic vein thrombosis. Although there is a significant bleeding risk from isolated gastric varices on long-term follow-up, there is no indication for the routine application of prophylactic


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Surgery_Schwartz. or splenic vein thrombosis. Although there is a significant bleeding risk from isolated gastric varices on long-term follow-up, there is no indication for the routine application of prophylactic measures.Patients with acute upper GI bleeding from isolated gas-tric varices should be considered high risk. Although data are limited, octreotide and/or vasopressin infusion may decease bleeding, if tolerated. Balloon tamponade with a Sengstaken-Blakemore tube may provide temporary control of exsanguinat-ing hemorrhage from type isolated gastric varices, but if this is used, endotracheal intubation for airway protection is prudent. Endoscopic treatment with sclerotherapy or varix ligation is less successful than in esophageal varices but should be con-sidered. Interventional radiology should be consulted and bal-loon-occluded retrograde transvenous obliteration considered. A transjugular intrahepatic portosystemic shunt (TIPSS) may be useful if there is nonsegmental portal hypertension. If


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Surgery_Schwartz. consulted and bal-loon-occluded retrograde transvenous obliteration considered. A transjugular intrahepatic portosystemic shunt (TIPSS) may be useful if there is nonsegmental portal hypertension. If the patient has splenic vein thrombosis and left-sided (sinistral) or segmental portal hypertension, splenectomy is quite effective in controlling bleeding from isolated gastric varices. The operative mortality is 5%. Liver transplantation should always be consid-ered in the cirrhotic patient.Hypertrophic Gastropathy (Ménétrier’s Disease)There are two clinical syndromes characterized by epithelial hyperplasia and giant gastric folds: ZES and Ménétrier’s dis-ease. The latter is characteristically associated with protein-losing gastropathy and hypochlorhydria. There are large rugal folds in the proximal stomach, and the antrum is usu-ally spared. Mucosal biopsy shows diffuse hyperplasia of the surface mucus-secreting cells and usually decreased parietal cells (Fig. 26-60). It has recently


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Surgery_Schwartz. proximal stomach, and the antrum is usu-ally spared. Mucosal biopsy shows diffuse hyperplasia of the surface mucus-secreting cells and usually decreased parietal cells (Fig. 26-60). It has recently been suggested that Méné-trier’s disease is caused by local overexpression of transform-ing growth factor-α in the gastric mucosa, which stimulates the epidermal growth factor receptor, a receptor tyrosine kinase, on gastric SECs. This results in the selective expan-sion of surface mucous cells in the gastric body and fundus. A few patients with this unusual disease have been successfully Figure 26-60. Mucosal biopsy in Ménétrier’s disease. (Repro-duced with permission from Ming S-C, Goldman H: Pathology of the Gastrointestinal Tract, 2nd ed. Baltimore, MD: Williams & Wilkins; 1998.)Brunicardi_Ch26_p1099-p1166.indd 115301/03/19 7:13 PM 1154SPECIFIC CONSIDERATIONS PART IItreated with the epidermal growth factor receptor blocking monoclonal antibody cetuximab.201Most patients with


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Surgery_Schwartz. 115301/03/19 7:13 PM 1154SPECIFIC CONSIDERATIONS PART IItreated with the epidermal growth factor receptor blocking monoclonal antibody cetuximab.201Most patients with Ménétrier’s disease are middle-aged men who present with epigastric pain, weight loss, diarrhea, and hypoproteinemia. There may be an increased risk of gastric cancer. Sometimes, the disease regresses spontaneously. Occa-sionally it is associated with H pylori infection, and the disease improves with helicobacter eradication. Total gastrectomy may be indicated for bleeding, severe hypoproteinemia, or cancer.Watermelon Stomach (Gastric Antral Vascular Ectasia)The parallel red stripes atop the mucosal folds of the distal stomach give this rare entity its sobriquet. Histologically, gas-tric antral vascular ectasia (GAVE) is characterized by dilated mucosal blood vessels that often contain thrombi, in the lamina propria. Mucosal fibromuscular hyperplasia and hyalinization often are present (Fig. 26-61). The


Surgery_Schwartz

Surgery_Schwartz. (GAVE) is characterized by dilated mucosal blood vessels that often contain thrombi, in the lamina propria. Mucosal fibromuscular hyperplasia and hyalinization often are present (Fig. 26-61). The histologic appearance can resemble portal hypertensive gastropathy, but the latter usually affects the proximal stomach, whereas watermelon stomach pre-dominantly affects the distal stomach. β-Blockers and nitrates, useful in the treatment of portal hypertensive gastropathy, are ineffective in patients with gastric antral vascular ectasia. Patients with GAVE are usually elderly women with chronic GI blood loss requiring transfusion. Most have an associated autoimmune connective tissue disorder, and at least 25% have chronic liver disease. Nonsurgical treatment options include estrogen and progesterone, and endoscopic treatment with the neodymium yttrium-aluminum garnet (Nd:YAG) laser or argon plasma coagulator.202 Antrectomy may be required to control blood loss, and this operation is quite


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Surgery_Schwartz. and endoscopic treatment with the neodymium yttrium-aluminum garnet (Nd:YAG) laser or argon plasma coagulator.202 Antrectomy may be required to control blood loss, and this operation is quite effective but carries increased morbidity in this elderly patient group. Patients with portal hypertension and antral vascular ectasia should be consid-ered for transjugular intrahepatic portosystemic shunt (TIPSS).Dieulafoy’s LesionDieulafoy’s lesion is a congenital arteriovenous malformation characterized by an unusually large tortuous submucosal artery. If this artery is eroded, impressive pulsatile bleeding may occur. To the endoscopist or surgeon, this appears as a stream of arte-rial blood emanating from what appears grossly to be a normal gastric mucosa. The lesion typically occurs in middle-aged or elderly men and may be more common in patients with liver disease.203 Patients typically present with upper GI bleeding, which may be intermittent, and endoscopy can miss the lesion if it is


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Surgery_Schwartz. or elderly men and may be more common in patients with liver disease.203 Patients typically present with upper GI bleeding, which may be intermittent, and endoscopy can miss the lesion if it is not actively bleeding. Treatment options include endoscopic hemostatic therapy, angiographic embolization, or operation. At surgery, the lesion may be oversewn or resected.Bezoars/DiverticulaBezoars are concretions of indigestible matter that accumulate in the stomach. Trichobezoars are composed of swallowed hair (Fig. 26-62). Phytobezoars are composed of vegetable matter and, in the United States, are usually seen in association with gastroparesis or gastric outlet obstruction. They also are asso-ciated with persimmon ingestion. Most commonly, bezoars produce obstructive symptoms, but they may cause ulceration and bleeding. Diagnosis is suggested by upper GI series and confirmed by endoscopy. Treatment options include enzyme therapy (papain, cellulase, or acetylcysteine), endoscopic


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Surgery_Schwartz. may cause ulceration and bleeding. Diagnosis is suggested by upper GI series and confirmed by endoscopy. Treatment options include enzyme therapy (papain, cellulase, or acetylcysteine), endoscopic dis-ruption and removal, or surgical removal.Gastric diverticula are usually solitary and may be con-genital or acquired. Congenital diverticula are true diverticula and contain a full coat of muscularis propria, whereas acquired diverticula (perhaps caused by pulsion) usually have a negli-gible outer muscle layer. Most gastric diverticula occur in the posterior cardia or fundus (Fig. 26-63) and are usually asymp-tomatic. However, they can become inflamed and may produce pain or bleeding. Perforation is rare. Asymptomatic diverticula do not require treatment, but symptomatic lesions should be removed. This can often be done laparoscopically.Foreign BodiesIngested foreign bodies are usually asymptomatic. Small coins usually pass through the GI tract without difficulty. Sharp or Figure


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Surgery_Schwartz. be removed. This can often be done laparoscopically.Foreign BodiesIngested foreign bodies are usually asymptomatic. Small coins usually pass through the GI tract without difficulty. Sharp or Figure 26-62. Trichobezoar forming cast of stomach and duode-num; removed from 15-year-old girl. (Reproduced with permission from DeBakey M, Ochsner A: Bezoars and concretions, Surgery. 1938;Dec;4:934.)Figure 26-61. Gastric antral vascular ectasia (watermelon stom-ach). (Reproduced with permission from Godlman H, Hayek J, Federman M: Gastrointestinal Mucosal Biopsy. New York, NY: Churchill Livingstone; 1996.)Brunicardi_Ch26_p1099-p1166.indd 115401/03/19 7:13 PM 1155STOMACHCHAPTER 26large objects in the stomach should be removed. This can usu-ally be done endoscopically, with an overtube technique. Rec-ognized dangers include aspiration of the foreign body during removal and rupture of drug-containing bags in “body packers.” Both complications can be fatal. Surgical removal is recom-mended in


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Surgery_Schwartz. Rec-ognized dangers include aspiration of the foreign body during removal and rupture of drug-containing bags in “body packers.” Both complications can be fatal. Surgical removal is recom-mended in body packers who ingest drug parcels for smuggling and in patients with large jagged objects that cannot be safely removed endoscopically. Corrosive objects (i.e., batteries) should be removed promptly usually endoscopically. Ingested magnets should be removed unless they are small and singular and without other ingested metal objects.Mallory-Weiss SyndromeThe Mallory-Weiss lesion is a longitudinal tear in the mucosa of the GE junction.204 It is presumably caused by forceful vom-iting and/or retching, and it is commonly seen in alcoholics. It presents with upper GI bleeding, often with hematemesis. Endoscopy confirms the diagnosis and may be useful in con-trolling the bleeding, but 90% of patients stop bleeding sponta-neously. Other options to control the bleeding include balloon tamponade,


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Surgery_Schwartz. Endoscopy confirms the diagnosis and may be useful in con-trolling the bleeding, but 90% of patients stop bleeding sponta-neously. Other options to control the bleeding include balloon tamponade, angiographic embolization, or selective infusion of vasopressin, systemic vasopressin, and operation. Surgical treat-ment consists of oversewing the bleeding lesion through a long gastrotomy.VolvulusGastric volvulus is a twist of the stomach that usually occurs in association with a large hiatal hernia. It also can occur in patients with an unusually mobile stomach without hiatal hernia. Typically, the stomach twists along its long axis (organoaxial volvulus), and the greater curvature flips up (Fig. 26-64C). If the stomach twists around the transverse axis, it is called mesentero-axial rotation (Fig. 26-64A and Fig. 26-64B). Often, volvulus is a chronic condition that can be surprisingly asymptomatic. In these instances, expectant nonoperative management is typi-cally advised, especially in


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Surgery_Schwartz. (Fig. 26-64A and Fig. 26-64B). Often, volvulus is a chronic condition that can be surprisingly asymptomatic. In these instances, expectant nonoperative management is typi-cally advised, especially in the elderly. The risk of strangulation and infarction has been overestimated in asymptomatic patients. Symptomatic patients should be considered for operation, espe-cially if the symptoms are severe and/or progressive. Patients may present with symptoms of pain and pressure related to the intermittently distending and poorly emptying twisted stomach. Pressure on the lung may produce dyspnea, pressure on the peri-cardium may produce palpitations, and pressure on the esopha-gus may produce dysphagia. Symptoms are often relieved with vomiting or passage of a nasogastric tube. Gastric infarction is a surgical emergency, and the patient can be moribund. Gastric necrosis may be extensive or focal. Elective operation for gas-tric volvulus usually involves reduction of the stomach and gas-tropexy


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Surgery_Schwartz. a surgical emergency, and the patient can be moribund. Gastric necrosis may be extensive or focal. Elective operation for gas-tric volvulus usually involves reduction of the stomach and gas-tropexy with or without repair of hiatal hernia. Gastropexy alone should be considered for high-risk patients since it can nearly always be performed laparoscopically and may be surprisingly effective in relieving mechanical symptoms.GASTROSTOMYA gastrostomy is performed either for alimentation or for gastric drainage/decompression. Gastrostomy may be done percutane-ously, laparoscopically, or via open technique.205,206 Currently, percutaneous endoscopic gastrostomy is the most common method used. The open techniques include the Stamm method (Fig. 26-65), the Witzel method (Fig. 26-66), and the Janeway method. The Janeway gastrostomy, designed to create a per-manent nondraining gastric stoma that can be intermittently intubated, is more complicated than the other open techniques, and is rarely


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Surgery_Schwartz. method. The Janeway gastrostomy, designed to create a per-manent nondraining gastric stoma that can be intermittently intubated, is more complicated than the other open techniques, and is rarely necessary. By far the most common surgical tech-nique is the Stamm gastrostomy, which can be performed open or laparoscopically.Complications of gastrostomy include infection, dis-lodgment, leakage with peritonitis, and aspiration pneumonia. Although gastrostomy tubes usually do prevent tense gastric dil-atation, they may not adequately drain the stomach, especially when the patient is bedridden, and they cannot always be relied upon to prevent pulmonary aspiration of gastric contents.ABCFigure 26-64. A through C. Gastric volvulus. (Reproduced with permission from Buchanan J: Volvulus of the stomach, Br J Surg. 1930;July;18(69):99-112.)Figure 26-63. Upper GI contrast study showing a diverticulum of the stomach. (Used with permission from Marc Levine, MD.)Brunicardi_Ch26_p1099-p1166.indd


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Surgery_Schwartz. Br J Surg. 1930;July;18(69):99-112.)Figure 26-63. Upper GI contrast study showing a diverticulum of the stomach. (Used with permission from Marc Levine, MD.)Brunicardi_Ch26_p1099-p1166.indd 115501/03/19 7:13 PM 1156SPECIFIC CONSIDERATIONS PART IIPOSTGASTRECTOMY PROBLEMS207Dumping SyndromeDumping is a phenomenon caused by the destruction or bypass of the pyloric sphincter.208 However, other factors undoubtedly play a role because dumping can occur after operations that pre-serve the pylorus, such as parietal cell vagotomy. Also, an appro-priate stimulus may provoke dumping symptoms, even in some patients who have not undergone surgery. Clinically significant dumping occurs in 5% to 10% of patients after pyloroplasty, pyloromyotomy, or gastrectomy, and consists of a constellation of postprandial symptoms ranging in severity from annoying to disabling. The symptoms are thought to be the result of the abrupt delivery of a hyperosmolar load into the small bowel due to ablation of


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Surgery_Schwartz. postprandial symptoms ranging in severity from annoying to disabling. The symptoms are thought to be the result of the abrupt delivery of a hyperosmolar load into the small bowel due to ablation of the pylorus or decreased gastric compliance. Typi-cally, 15 to 30 minutes after a meal, the patient becomes dia-phoretic, weak, light-headed, and tachycardic. These symptoms may be ameliorated by recumbence or saline infusion. Crampy abdominal pain is not uncommon, and diarrhea often follows. This is referred to as early dumping and should be distinguished from postprandial (reactive) hypoglycemia, also called late dumping, which usually occurs later (2–3 hours following a meal) and is relieved by the administration of sugar. A variety Figure 26-65. Stamm gastrostomy. (Reproduced with permission from Zuidema GD, Yeo CJ: Shackelford’s Surgery of the Alimentary Tract, 5th ed. Vol. II. Philadelphia, PA: Elsevier/Saunders; 2002.)Figure 26-66. A through F. Witzel gastros-tomy. (Reproduced with


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Surgery_Schwartz. from Zuidema GD, Yeo CJ: Shackelford’s Surgery of the Alimentary Tract, 5th ed. Vol. II. Philadelphia, PA: Elsevier/Saunders; 2002.)Figure 26-66. A through F. Witzel gastros-tomy. (Reproduced with permission from Zuidema GD, Yeo CJ: Shackelford’s Sur-gery of the Alimentary Tract, 5th ed. Vol. II. Philadelphia, PA: Elsevier/Saunders; 2002.)Brunicardi_Ch26_p1099-p1166.indd 115601/03/19 7:13 PM 1157STOMACHCHAPTER 26of hormonal aberrations have been observed in early dumping, including increased serum levels of VIP, CCK, neurotensin, peripheral hormone peptide YY, renin-angiotensin-aldosterone, and decreased atrial natriuretic peptide. Late dumping is associ-ated with hypoglycemia and hyperinsulinemia.Medical therapy for the dumping syndrome consists of dietary modification and somatostatin analogue (octreotide). Often, symptoms improve if the patient avoids liquids during meals. Hyperosmolar liquids (e.g., milk shakes) may be particu-larly troublesome. There is some evidence that


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Surgery_Schwartz. analogue (octreotide). Often, symptoms improve if the patient avoids liquids during meals. Hyperosmolar liquids (e.g., milk shakes) may be particu-larly troublesome. There is some evidence that adding dietary fiber compounds at mealtime may improve the syndrome. If dietary manipulation fails, the patient is started on octreotide, 100 μg subcutaneously twice daily. This can be increased up to 500 μg twice daily if necessary. The long-acting depot octreo-tide preparation is useful. Octreotide not only ameliorates the abnormal hormonal pattern seen in patients with dumping symptoms, but it also promotes restoration of a fasting motility pattern in the small intestine (i.e., restoration of the MMC). The α-glucosidase inhibitor acarbose may be particularly helpful in ameliorating the symptoms of late dumping.Only a very small percentage of patients with dumping symptoms ultimately require surgery. Most patients improve with time (months and even years), dietary management, and medication.


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Surgery_Schwartz. of late dumping.Only a very small percentage of patients with dumping symptoms ultimately require surgery. Most patients improve with time (months and even years), dietary management, and medication. Therefore, the surgeon should not rush to reoper-ate on the patient with dumping symptoms. Multidisciplinary nonsurgical management must be optimized first. Before reop-eration, a period of inhospital observation is useful to define the severity of the patient’s symptoms and patient compliance with prescribed dietary and medical therapy.The results of remedial operation for dumping are variable and unpredictable. There are a variety of surgical approaches, none of which work consistently well. Addition-ally, there is not a great deal of experience reported in the literature with any of these methods and long-term follow-up is rare. Patients with disabling refractory dumping after gas-trojejunostomy can be considered for simple takedown of this anastomosis provided that the pyloric channel


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Surgery_Schwartz. and long-term follow-up is rare. Patients with disabling refractory dumping after gas-trojejunostomy can be considered for simple takedown of this anastomosis provided that the pyloric channel is patent. The reversed intestinal segment is rarely used today—and rightly so. This operation interposes a 10-cm reversed segment of intestine between the stomach and the proximal small bowel. This slows gastric emptying, but often leads to obstruction, requiring reoperation. Isoperistaltic interposition (Henley loop) has not been successful in ameliorating severe dumping over the long term. The Roux-en-Y gastrojejunostomy is asso-ciated with delayed gastric emptying, probably on the basis of disordered motility in the Roux limb. Taking advantage of this disordered physiology, surgeons have used this operation successfully in the management of the dumping syndrome. Although this is probably the procedure of choice in the small group of patients requiring operation for severe dumping fol-lowing


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Surgery_Schwartz. operation successfully in the management of the dumping syndrome. Although this is probably the procedure of choice in the small group of patients requiring operation for severe dumping fol-lowing gastric resection, gastric stasis may result, particularly if a large gastric remnant is left. In the presence of significant gastric acid secretion, marginal ulceration is common after both jejunal interposition and Roux-en-Y procedures; thus, concomitant vagotomy and hemigastrectomy should be con-sidered. The theoretical possibility of treating postpyloroplasty dumping with a Roux-en-Y to the proximal duodenum (the duodenal switch, a potentially reversible operation) has not yet been reported (Fig. 26-67). Because pyloric ablation seems to be the dominant factor in the etiology of dumping, it is not sur-prising that conversion of Billroth II to Billroth I anastomosis has not been successful in the treatment of dumping.DiarrheaDiarrhea following gastric surgery may be the result of trun-cal


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Surgery_Schwartz. not sur-prising that conversion of Billroth II to Billroth I anastomosis has not been successful in the treatment of dumping.DiarrheaDiarrhea following gastric surgery may be the result of trun-cal vagotomy, dumping, or malabsorption. Truncal vagotomy is associated with clinically significant diarrhea in 5% to 10% of patients. It occurs soon after surgery and usually is not associ-ated with other symptoms, a fact that helps to distinguish it from dumping. The diarrhea may be a daily occurrence, or there may be significant periods of relatively normal bowel function. The symptoms tend to improve over the months and years after the index operation. The cause of postvagotomy diarrhea is unclear. Possible mechanisms include intestinal dysmotility and accel-erated transit, bile acid malabsorption, rapid gastric emptying, and bacterial overgrowth. The latter problem is facilitated by decreased gastric acid secretion and (even small) blind loops. Although bacterial overgrowth can be


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Surgery_Schwartz. rapid gastric emptying, and bacterial overgrowth. The latter problem is facilitated by decreased gastric acid secretion and (even small) blind loops. Although bacterial overgrowth can be confirmed with the hydrogen breath test, a simpler test is an empirical trial of oral antibiotics. Some patients with postvagotomy diarrhea respond to cholestyramine, while in others codeine or loperamide may be useful. Octreotide should also be tried. Another theoretical cause of diarrhea following gastric surgery is fat malabsorption due to acid inactivation of pancreatic enzymes or poorly coor-dinated mixing of food and digestive juices. This can be con-firmed with a qualitative test for fecal fat and treated with acid suppression. Postvagotomy diarrhea usually does not respond to treatment with pancreatic enzymes. In the rare patient who is debilitated by postvagotomy diarrhea unresponsive to medical management, operation might be considered, but outcomes can be problematic. The operation of


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Surgery_Schwartz. enzymes. In the rare patient who is debilitated by postvagotomy diarrhea unresponsive to medical management, operation might be considered, but outcomes can be problematic. The operation of choice is probably a 10-cm reversed jejunal interposition placed in continuity 100 cm distal to the ligament of Treitz. Another option is the onlay antiperi-staltic distal ileal graft. Both operations can cause obstructive symptoms and/or bacterial overgrowth.209Gastric Stasis210,211Gastric stasis following surgery on the stomach may be due to a problem with gastric motor function or caused by an obstruc-tion. The gastric motility abnormality could have been preexist-ing and unrecognized by the operating surgeon. Alternatively, Figure 26-67. Duodenal switch operation. (Reproduced with per-mission from Hinder RA: Duodenal switch: a new form of pancreati-cobiliary diversion, Surg Clin North Am. 1992 Apr;72(2):487-499.)Brunicardi_Ch26_p1099-p1166.indd 115701/03/19 7:13 PM 1158SPECIFIC


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Surgery_Schwartz. from Hinder RA: Duodenal switch: a new form of pancreati-cobiliary diversion, Surg Clin North Am. 1992 Apr;72(2):487-499.)Brunicardi_Ch26_p1099-p1166.indd 115701/03/19 7:13 PM 1158SPECIFIC CONSIDERATIONS PART IIit may be secondary to deliberate or unintentional vagotomy, or resection of the dominant gastric pacemaker. An obstruction may be mechanical (e.g., anastomotic stricture, efferent limb kink from adhesions or constricting mesocolon, or a proximal small-bowel obstruction) or functional (e.g., retrograde peristal-sis in a Roux limb). Gastric stasis presents with vomiting (often of undigested food), bloating, epigastric pain, and weight loss.The evaluation of a patient with suspected postoperative gastric stasis includes EGD, upper GI and small bowel series, gastric emptying scan, and gastric motor testing. Endoscopy shows gastritis and retained food or bezoar. The anastomosis and efferent limb should be evaluated for stricture or narrow-ing. A dilated efferent limb


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Surgery_Schwartz. scan, and gastric motor testing. Endoscopy shows gastritis and retained food or bezoar. The anastomosis and efferent limb should be evaluated for stricture or narrow-ing. A dilated efferent limb suggests chronic stasis, either from a motor abnormality (e.g., Roux syndrome) or mechanical small bowel obstruction (e.g., chronic adhesion). If the problem is thought to be primarily a disorder of intrinsic motor func-tion, newer techniques such as EGG and GI manometry should be considered, but chronic distal mechanical obstruction may result in disordered motility in the proximal organ confounding interpretation.Once mechanical obstruction has been ruled out, medi-cal treatment is successful in most cases of motor dysfunction following previous gastric surgery. This consists of dietary modification and promotility agents. Intermittent oral antibiotic therapy may be helpful in treating bacterial overgrowth, with its attendant symptoms of bloating, flatulence, and diarrhea.Gastroparesis


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Surgery_Schwartz. and promotility agents. Intermittent oral antibiotic therapy may be helpful in treating bacterial overgrowth, with its attendant symptoms of bloating, flatulence, and diarrhea.Gastroparesis following V + D may be treated with subto-tal gastrectomy but simple loop gastrojejunoctomy (GJ) should be tried if previous drainage was pyloroplasty. Billroth II anas-tomosis with Braun enteroenterostomy may be preferable to Roux-en-Y reconstruction after subtotal gastrectomy for gas-tric stasis, but bile reflux can still occur. Initial operation for gastric stasis is often associated with persistent gastric empty-ing problems that may subsequently require near-total or total gastrectomy, a nutritionally unattractive option. Delayed gastric emptying following ulcer surgery (V + D or V + A) may rep-resent an anastomotic stricture (often due to recurrent ulcer) or proximal small bowel obstruction. Recurrent ulcer may respond to medical therapy with PPI and abstinence from NSAIDs, aspi-rin, and


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Surgery_Schwartz. an anastomotic stricture (often due to recurrent ulcer) or proximal small bowel obstruction. Recurrent ulcer may respond to medical therapy with PPI and abstinence from NSAIDs, aspi-rin, and smoking. And if necessary, endoscopic dilation is occa-sionally helpful. However, when associated with symptomatic gastric stasis, reoperation is often necessary. Gastroparesis fol-lowing subtotal gastric resection is best treated with near-total (95%) or total gastric resection and Roux-en-Y reconstruction. If total gastrectomy is performed, a jejunal reservoir should be considered. Gastric pacing is promising, but it has not achieved widespread clinical usefulness in the treatment of postoperative gastric atony.Bile Reflux Gastritis and EsophagitisMost patients who have undergone ablation or resection of the pylorus have bile in the stomach on endoscopic examination, along with some degree of gross or microscopic gastric inflam-mation. Therefore, attributing postoperative symptoms to bile reflux


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Surgery_Schwartz. of the pylorus have bile in the stomach on endoscopic examination, along with some degree of gross or microscopic gastric inflam-mation. Therefore, attributing postoperative symptoms to bile reflux is problematic because most asymptomatic patients have bile reflux too. However, it is generally accepted that a small subset of patients have bile reflux gastritis syndrome. These patients present with nausea, bilious vomiting, and epigastric pain, and quantitative evidence of excess enterogastric reflux. Curiously, symptoms often develop months or years after the index operation. The differential diagnosis includes afferent or efferent loop obstruction, gastric stasis, and small-bowel obstruction. Plain abdominal X-rays, upper endoscopy, upper GI series, abdominal CT scan, and gastric emptying scans are helpful in evaluating these possibilities.Bile reflux may be quantified with gastric analysis or esophageal impedance testing or with scintigraphy (bile reflux scan). Typically,