Tumor Board

1
Tumor Board

• 11/28/2006

2
HPI

• WC- 31 year-old AA M initially in 2004 by another
  physician, for symptoms of gastroesophageal
  reflux disease ( e.g. heartburn, regurgitation,
  nausea)
• PMHx- Crohns Disease (on prednisone up until 2
  yrs prior)
• PSHx-none
• Allergies-none

3
HPI

• Endoscopy- showed a number of large gastric
  polyps occupying the majority of his stomach
  cavity. Biopsies revealed hyperplastic polyps
  with dysplastic changes
• He was given an option of a Total Gastrectomy or
  to have an excision of the polyps

4
HPI

• He chose the latter, which was also recommended
  by the physician
• would allow to evaluate for malignancy
• would allow for time interval to evaluate
  regrowth of polyps
• 7/19/05- OPERATION
• Diagnostic laparoscopy
• Longitundinal gastrotomy
• Open incision with excision of 3 friable polyps
• each polyp 10-12 cm in size

5
HPI

• Pathology
• All 3 specimens were noted to be hyperplastic
  polyps
• One of these specimens were biopsied and sent to
  another lab for analysis
• Adenomatous with High Grade Glandular Epithelial
  Dysplasia
• Fragments of hyperplastic polyp

6
HPI

• Pt referred to Dr. Didolkar for further treatment
• Decision made to attempt more definitive
  procedure
• Total Gastrectomy

7
Brief Operative Note

• Pre Operative Dx
• Multiple polyps throughout the stomach as well as
  dysplastic polyps, previous partial gastrectomy
  through laparoscopy
• Post Operative Dx
• Multiple polyps throughout the stomach as well as
  dysplastic polyps, previous partial gastrectomy
  through laparoscopy
• Procedure Total gastrectomy Roux-en-Y
  esophagojejunostomy, and jejunojejunosotmy
• Specimen- Stomach
• EBL- 1.0 L
• Complications-none

8
Postoperative Course

• POD1- Extubated in ICU
• Vitals stable
• POD2- Transferred to the floor
• POD5- Return of bowel function
• POD6- Pt. discharged

9
Management of Gastric Polyposis

• 11/28/2006

10
Gastric Polyposis
11
Gastric Polyposis

• The widespread use of endoscopy has increased the
  frequency of detection of gastric wall lesions in
  symptomatic and asymptomatic patients
• All layers of the stomach wall have the potential
  to produce tumorous growths
• 40 of patients with benign gastric tumors are
  mucosal based
• Another 40 are muscularis based

12
Gastric Polyposis

• Types of polyps include the following
• Hyperplastic polyps
• Adenomatous polyps
• Fundic gland polyps
• Inflammatory fibroid polyps
• Juvenile polyps
• Familial polyposis syndromes
• Peutz-Jeghers syndrome
• Nonmucosal intramural tumors
• Leiomyoma

13
Gastric Polyposis

• Types
• Hyperplastic
• Hyperplastic polyps are by far the most common
  histologic type, and they can vary in location,
  number, and size
• Most are less than 2 cm
• these polyps usually harbor no malignancy
• Adenomatous
• usually solitary lesions in the antrum
• atypical cells and are associated with
  adenocarcinoma of the stomach
• overall incidence of malignant transformation in
  adenomatous polyps is about 3.4

14
Gastric Polyposis

• Frequency
• Benign tumors of the stomach are found in 1 of
  patients undergoing gastroscopy
• Clinical
• Small tumors are usually asymptomatic, may be
  found incidentally
• larger tumors can ulcerate and cause occult
  bleeding and anemia
• Large antral tumors cause intermittent gastric
  outlet obstruction as manifested by nausea,
  vomiting, and early satiety

15
Gastric Polyposis

• Physical
• May be large enough to allow for palpation
• Abdominal exam can lead to tenderness
• Diagnosis
• Imaging
• Ct Abd or UGI study
• Procedure
• Endoscopy has become more common for both
  diagnostic and therapeutic purposes
• Endoscopic findings that suggest malignancy
  include red coloring, the presence of surface
  erosions, and the absence of a pedicle

16
Gastric Polyposis

• Treatment
• Polyps smaller than 2 cm are easily snared
• Larger polyps or sessile polyps are best removed
  operatively to obtain a clear margin and complete
  removal
• Wide, local, or segmental resection of the
  stomach may be performed for multiple polyps,
  depending on their histology and location
• Gastrectomy is justified in patients with diffuse
  involvement of the stomach by polyps, which can
  make detection of a synchronous focus of cancer
  difficult