Oncological Emergency : Gastric Cancer

Abdominal (Gastric Cancer) - Ahmad Abid

Solid organ (HCC) – Ahmad Ashraf

Upper extremities – Ahmad Danial

Lower extremities – Ahmad Farabi

Head and Neck- Adiba & Adibah

General – Khaireza (state of consciousness and hemorrhage)

Ahmad Abid Bin Abas 07-6-2

More prominent in case of advanced gastric cancer.

Early satiety,bloating,distension and vomiting may occur.

If tumour bleeds will lead to iron def. anemia.

Obstruction will lead to dysphagia,epigastric fullness or vomiting.

With pyloric involvement will lead to gastric outlet obst.

Metastatic LN may be palpable (Virchow’s Nodes)

Medical Hx/Phys. Exam (Signs and symptoms)

Lab tests – CBC, LFT,RFT,CarcinoembryonicAg. and CA19.9

EGD and Biopsy,EUS guided biopsy,CT guided needle biopsy.

Imaging – Barium Swallow,CT Scan,MRI,CXRfor metastatic lesion.

Surgery,Chemotherapy,Radiation,LN Removal D1,D2.

Emergency surgery within 24h of presentation for gastric malignancy is extremely rare.

Presentation :

1. Haematemesis

2. Visceral perforation

3. Gastric Outlet Obstruction

PE : Severe abdomen tenderness suggests GI bleeding assoc. with GI Obst,GI perforation and bowel ischemia.

Two-staged procedural approach.

1. First stage – Control the perforation,bleedingand obstruction.

(Emergency lifesaving intervention)

2. Second stage – Definitive gastrectomy with LN dissection after histological confirmation and accurate staging.

(Emergency cancer therapy)

Nasogastric aspiration with saline lavage.

(Detection intragastric bleeding,type of bleeding-

red blood/coffee ground,endoscopicvisualization,prevent aspiration of gastric

contents.)

General Measure : (fluid replacement,bloodtransfusion,care of abdomen from further trauma,cardiorespiratory support,Rxcomorbid disease like sepsis,coronary artery disease.)

*EGD should be delayed until patient is adequately

resuscitated and stabilized.

Specific measures : EGD (procedure of choice,diagnostic

and therapeutic tool for UGIB)

1. Injection therapy (adrenaline)

2. Ablative therapy (electrocautery,argonplasma coagulation)

3. Mechanical therapy (endoclips or banding)

May require surgery for bleeding control if endoscopic measures for hemostasis fail.

1. Endoscopic stenting

http://www.hopkins-gi.org/GDL_Disease.aspx?CurrentUDV=31&GDL_Cat_ID=AF793A59-B736-42CB-9E1F-E79D2B9FC358&GDL_Disease_ID=DB2F8EAC-4421-41DD-B04E-684AFEF2AD94

(Surgical) :

1. Surgical bypass with gastrojejunostomy.

2. Palliative distal gastrectomy.

Exploratory laparotomy and application of Omental patch (Graham patch)

Peritoneal washout - peritoneal cavity is to be irrigated with 10 liters of warm saline solution to remove further contamination.

http://www.saudijgastro.com/article.asp?issn=1319-3767;year=2011;volume=17;issue=2;spage=124;epage=128;aulast=Maghsoudi

Closed suction drainage/Jacksonn Patt drain placement.

Site : suprahepatic and infrahepatic recesses, the lesser sac, the paracolic gutters, and pelvis.

Crystalloid solutions.

The goals of resuscitation focus on urinary output, lactic acid levels, mean arterial pressure, and central venous pressure parameters.

Jejunostomy feeding tube.

http://www.uofmmedicalcenter.org/healthlibrary/Article/86497

Oral feeding is likely to be delayed.

Intraoperative placement of a jejunostomyfeeding tube may be benefit the patient.

Alternative : Intraoperative or postoperative placement of a double lumen gastro-jejunaltube.

Catheters - Parenteral nutrition sometimes used.

*Generally, enteral nutrition distal to the perforation would be

preferable if possible.

http://emedicine.medscape.com/article/1892935-overview#aw2aab6b5

http://patients.gi.org/topics/enteral-and-parenteral-nutrition/

“Antimicrobial therapy should be continued postoperatively for 24 hours when the perforation has been surgically closed in the first 12 hours” - Infectious Guidelines of the Disease Society of

America and Surgical Infection Society

Goals : Normalization of WBC counts and temperature after 24h postoperatively.

If does not occur,antimicrobials can be continued for 4-7 days.

Preferred agents include a beta-lactam/beta-lactamaseinhibitor combination or a carbapenem.

H pylori eradication should also be considered.

http://emedicine.medscape.com/article/1892935-overview#aw2aab6b5

Following patient recovery and histological confirmation of malignancy, accurate disease staging can be completed, and a radical oncological operation for gastric cancer or neoadjuvant chemotherapy can be planned as appropriately.