Morbidity

1
Morbidity MortalityConference

• 8/21/07

2
HPI

• HC
• 75 y/o M with PMHx of HTN presented to PMD with 2
  week of abdominal pain with N/V also c/o early
  satiety and periodic reflux
• Intermittent nonbilious vomiting some evidence
  of weight loss
• Vitals stable
• PE
• Abd- mild distention, soft to firm , NT,
  BS-active

3
HPI

• Differential
• Gastric CA
• Esophageal CA
• Pancreatic CA
• PUD

4
Work Up

• Colonoscopy
• Normal
• Endoscopy
• Single large malignant sessile ulcerated mass
• Biopsy- poorly differentiated infiltrating
  adenocarcinoma
• Pylorus and duodenum appeared normal

5
Gastric Ca

• Surgical Oncology consulted
• CT ABD PELV obatained
• Showed mass in distal stomach with no evidence of
  metastasis
• Plan
• Exploratory Laparotomy with possible resection of
  Gastric tumor

6
Operative Report

• Post Op Dx- Metastatic Gastric Ca to the liver
  and locally advanced disease to 1st portion of
  duodenum
• Procedure
• Subtotal gastrectomy
• Liver nodule excisional bx
• Cholecystectomy

7
Operative Report

• Details
• Significant disease felt at distal stomach
• Dissection taken proximally
• Greater and lesser curvature dissected
• Midportion of stomach transected
• Dissection continued toward the Right side
• Noticed bulky lymph node disease just below 1st
  portion of duodenum
• Went past that point and transected at about the
  2nd portion of duodenum
• Acknowledged that distal margin not clear
• Cholecystectomy
• Gastrojejunostomy
• Biopsy of liver nodules

8
Pathology

• Subtotal gastrectomy
• Adenocarcinoma
• Proximal margin-clear
• Distal margin-not clear
• Lymph node-all 20 nodes are positive
• Cholecystectomy
• Chronic Calculous Cholecystitis
• Liver nodules
• Adenocarcinoma c/w Gastric tumor metastasis

9
Post Operative Course

• Stable on floor
• Tolerating PO diet
• No acute events during postoperative course
• Probable discharge today

10
Literature

• Gastric Ca
• 22,000 cases per year
• 13,000 deaths per year
• 15 to 20 5 yr survival rate
• Types
• Adenocarcinoma- 95
• Squamous cell Ca
• Carcinoid
• GIST
• Lymphoma

11
Literature

• Pathologic staging is based on tumor stage, nodal
  stage, and metastasis stage (TMN).
• T stage - Extent of penetration through the
  gastric wall
• Tis - Carcinoma in situ, intraepithelial tumor
• T1 - Tumor extension to submucosa
• T2 - Tumor extension to the muscularis propria or
  subserosa
• T3 - Tumor penetration of the serosa
• T4 - Tumor invasion of the adjacent organs
• N stage - Number and site of draining lymph nodes
  involved (see also N staging below)
• N0 - No lymph nodes involved
• N1 - Metastases in 1-6 regional lymph nodes
• N2 - Metastases in 7-15 regional lymph nodes
• N3 - Metastases in gt15 regional lymph nodes
• M stage - Presence of metastases
• M0 - No distant metastases
• M1 - Distant metastases

12
Literature

• Staging and 5-Year Survival Rates
• Stage TNM Stage 5-Year Survival
• 1 T1N0M0, T1N1M0, or T2N0M0 88
• 2 T1N2M0, T2N1M0, or T3N0M0 65
• 3a T2N2M0, T3N1M0, or T4N0M0 35
• 3b T3N2M0 35
• 4 T4N1-3M0, TxN3M0, or TxNxM1 5
• Tx indicates any T stage Nx, any N stage.

13
Literature

• Sites of Metastasis
• Liver 38-54
• Peritoneum 17-24
• Omentum 13-21
• Lungs 12-22

14
Literature

• Controversies
• Role of Endoscopic Ultrasound in staging pts with
  gastric ca
• Extent of lymph node dissection D1 vs D2
• Role of Neoadjuvant treatment

15
Literature

• Endoscopic ultrasound
• Found to be highly effective in discriminating T
  staging (T1 vs T2 vs T3 vs T4
• Lymph Node dissection
• Dutch Gastric Cancer study
• Randomized controlled trial (dutch cancer group)
• 10 year period
• N-732- patients with tumors after resection with
  curative intent
• D1 N380 D2 N-331
• Hospital days 14 16
• Complication 25 43
• Relapse risk 8 6

16
Literature

• Adjuvant chemotherapy
• Between 1994 and 2002, the researchers recruited
  503 patients
• 74 with gastric cancer
• 11 with cancer of the esophago-gastric junctio
• 15 with cancer of the lower esophagus.
• Two hundred fifty patients were randomized to
  three cycles of chemotherapy with Ellence-
  cisplatin-5-fluorouracil, followed by surgery
  three to six weeks after the last cycle of
  chemotherapy
• Three cycles of adjuvant chemotherapy were
  initiated 6 to 12 weeks after surgery
• hazard ratio for progression free survival in the
  adjuvant-plus-neoadjuvant therapy arm was 0.66
  (95 C.I. 0.53-0.81), which was significant (P
  0.0001)

17
Literature

• Overall
• Need proper w/u
• HP, Blood work, Upper Endoscopy /-EUS with Bx,
  CT AP
• Surgical Trament
• Laparoscopy
• Some studies show an almost 30 of diognosis of
  metastatic disease
• Resection- gt5cm and at least 15 nodes
• D1 dissection sufficient
• Use of Neoadjuvant therapy

18
HPI

• MA
• 85 y/o M with a known history of chronic
  myelodysplastic disease
• Past 6 months, has had a rapid enlargement of his
  spleen with resultant painful early satiety on
  eating and dyspnea on minimal exertion
• Also, c/o B/L Lower Extremity edema
• Due to new onset symptoms
• Surgical Oncology was consulted for possible
  Splenectomy

19
Morbidity Mortality

• PMHx-Prostate Ca, Gout
• PSHx-Pinning for Left hip fx (2005)
• FHx- Mother died of heart disease
• SHx- denies alcohol, drugs, or smoking
• Meds- Allopurinol, Lasix, Tylenol, Protonix
• Allergies- NKDA
• Vitals- T-36.7 P-72 BP-112/51 100 2L NC
• Gen- AA0 x3 NAD
• HEENT- PERRL, EOMI, no Lymphadenopathy, no
  carotid bruits
• CVS- RRR no gallops, no murmurs
• Lungs- CTA B, diminshed on B/L Bases
• ABD- Soft, NT, Distentsion, BS-active liver
  edge palpable to below level of umbilicus
• EXT- 2 pitting edema
• Neuro- No Neurologic deficit

20
Labarotory

• CBC
• WBC- 5.3 Hgb/Hct-7.9/24.0 Plts-38
• CMP
• Na-142 K-4.1 Cl-107 CO2-25 BUN-37 Crea-.91
  Gluc-103
• INR- 1.2

21
Radiology

• CT AP
• Hapatosplenomegaly
• Prostate Ca with metastasis to bone

22
Ct Scan
23
Morbidity and Mortality

• A/P
• 86/yo male with myelodysplastic disease
  presenting with chronic anemia and
  thrombocytopenia
• Plan transfuse 2 units PRBC and 2 6 pack of Donor
  Platelets
• Medically optimize for Surgical Intervention

24
Operative Report

• Post-Operative Dx
• Myelodysplastic disease with severe hypersplenism
• Procedure
• Splenic flexure takedown
• Splenectomy
• Details of Porcedure
• Midline incision
• Splenic Artery tortuous
• Enlarged spleem
• 30 x 21 x 9.5 cm
• 3.6 gm
• 500 cc of blood loss
• JP drain placed
• Abdomen examined and irrgiated thoroughly
• Pt in stable condition, taken to ICU

25
Post Operative Course

• Pt. became transiently hypotensive Hct dropped
  from 31 (postoperatively) to 19 (w/n 5 hours)
• Family notified and consented for surgery
• Patient taken back to the OR
• Details of Procedure
• Significant amount of non clotted blood
  encountered in abdomen (3L)
• Arterial bleeding from omental area
• 1mm area noted and ligated
• Small Arterial bleeding at colonic mesentery
• Area noted and ligated
• Generalized venous oozing
• Surgical Packing
• Argon Beam laser coagulation
• JP drain placed

26
Morbidity Mortality
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28
Post Operative Course

• Pt remained intubated
• Extubated on POD4
• H/H stablized
• Received 2 units of PRBC over 5 day ICU course
• No significant drop in H/H noted
• Maintained strong urine output
• Gentle diuresis on POD4

29
Post Operative Course

• Currently
• Stable on floor
• SW
• PT/OT
• Drain removed
• OOB/AMB
• Plan
• Disposition planning