An adult presented with hemetemesis and upper abdominal pain. Endoscopy revealed a growth at the pyloric antrum of the stomach. CT scan showed growth involving the pyloric antrum without infiltration or invasion into surrounding structures and no evidence of distant metastasis. At Laparotomy neoplastic growth was observed to involve the posterior wall of stomach and the pancreas extending 6cm up to tail of pancreas. What will be the most appropriate surgical management:
Answer is C (Paial Gastrectomy + Distal pancreatectomy) Paial gastrectomy with distal pancreatectomy should be adequate to manage this distal gastric tumor with direct invasion into the distal pancreas. Tumors of the distal third / antrum of stomach require a subtotal gastrectomy (Paial gastrectomy). The distal pancreas should be removed as there is direct invasion of the distal pancreas. Splenectomy is not indicated as the tumor does not directly invade the spleen, and involvement of splenic hilar lymph nodes is unlikely as the tumor is located in the distal third of the stomach (and not in the proximal stomach). This patient is best managed by subtotal gastrectomy + lymphadenectomy + distal pancreatectomy. Guidelines for management of Gastric carcinoma Surgical resection remains the mainstay of treatment of gastric cancer either for cure or for palliation The extent of gastric resection depends on the site of tumor in the stomach. Tumors in the distal third or antrum of stomach require a subtotal gastrectomy (paial gastrectomy) while tumors of the middle or proximal third of the stomach require a total gastrectomy Distal Third /Antrurn Gastric cancer Middle Third /Proximal Gastric cancer Subtotal Gastrectomv Total Gastrectomy The extent of resection of adjacent structures (pancreas, spleen etc) depends on the location of primary tumor and local invasion Pancreatic Resection The distal pancreas should not be removed a pa of a resection for a cancer of the distal two third of the stomach (unless there is direct invasion) The distal pancreas should be removed only when there is direct invasion and still a chance of a curative procedure in patients with carcinoma of the proximal stomach Splenic resection Splenectomy is not indicated unless the tumor directly invades the spleen or involves the splenic hilar lymph nodes. Resection of spleen and splenic hilar lymph nodes may be considered in patients with tumors of the proximal stomach located in the greater curvature / posterior wall of the stomach close to the splenic hilum where the incidence of splenic hilar nodal involvement is likely to be high.
Closure of the abdomen
Antrectomy and vagotomy
Paial Gastrectomy + Distal pancreatectomy
Paial Gastrectomy + Distal pancreatectomy + splenectomy