A 55-year-old executive who is seen because of severe epigastric pain is found on esophagogastroduodenoscopy to have a large ulcer in the duodenal bulb and tests positive for H. pylori. He is treated for H. pylori and instructed to quit smoking, but his symptoms persist and he is referred to you for further management. At this time, it would be most appropriate to recommend:
The indications for surgery in PUD are bleeding, perforation, obstruction, and intractability or nonhealing. Intractability should be an unusual indication for peptic ulcer operation nowadays. The patient referred for surgical evaluation because of intractable PUD should raise red flags for the surgeon: maybe the patient has a missed cancer, is noncompliant, or has Helicobacter despite the presence of a negative test or previous treatment (differential for intractability, Table below). In this setting, the patient with persistent symptoms despite appropriate treatment requires further evaluation before any consideration of operative treatment. If surgery is necessary, a lesser operation may be preferable.
Differential diagnosis of intractability or non-healing peptic ulcer disease:
Which blood group is associated with an increased risk of gastric cancer?
Gastric cancer is more common in patients with pernicious anemia, blood group A, or a family history of gastric cancer. When patients migrate from a high-incidence region to a low-incidence region, the risk of gastric cancer decreases in the subsequent generations born in the new region. This strongly suggests an environmental influence on the development of gastric cancer. Environmental factors appear to be more related etiologically to the intestinal form of gastric cancer than the more aggressive diffuse form. The commonly accepted risk factors for gastric cancer are listed in Table below.
Factors increasing or decreasing the risk of gastric cancer:
A subtotal gastrectomy with D2 dissection performed for Stage 3 gastric adenocarcinoma in the antrum includes:
Surgical resection is the only curative treatment for gastric cancer and most patients with clinically resectable locoregional disease should have gastric resection. The standard operation for gastric cancer is radical subtotal gastrectomy, which entails ligation of the left and right gastric and gastroepiploic arteries at the origin, as well as the en bloc removal of the distal 75% of the stomach, including the pylorus and 2 cm of duodenum, the greater and lesser omentum, and all associated lymphatic tissue. Generally, the surgeon strives for a grossly negative margin of at least 5 cm. More than 15 resected lymph nodes are required for adequate staging, even in the low-risk patient. The operation is deemed an adequate cancer operation provided that tumor-free margins are obtained, > 15 lymph nodes are removed, and all gross tumor is resected. In the absence of involvement by direct extension, the spleen and pancreatic tail are not removed. Reconstruction is usually by Billroth I gastrojejunostomy or Roux-en-Y reconstruction.
The standard treatment for an isolated 3 cm gastrointestinal stromal tumor (GIST) in the body of the stomach is:
Gastrointestinal stromal tumors (GISTs) are submucosal tumors that are slow growing, and arise from interstitial cells of Cajal (ICC). Prognosis in patients with GISTs depends mostly on tumor size and mitotic count, and metastasis, when it occurs, is typically by the hematogenous route. Any lesion >1 cm can behave in a malignant fashion and may recur. Thus, all GISTs are best resected along with a margin of normal tissue-wedge resection with clear margins is adequate surgical treatment. True invasion of adjacent structures by the primary tumor is evidence of malignancy. If safe, en bloc resection of involved surrounding organs is appropriate to remove all tumor when the primary is large and invasive. Five-year survival following resection for GIST is about 50%. Most patients with low-grade lesions are cured (80% 5-year survival), but most patients with high-grade lesions are not (30% 5-year survival). Imatinib, a chemotherapeutic agent that blocks the activity of the tyrosine kinase product of c-kit, yields excellent results in many patients with metastatic or unresectable GIST, and is also recommended in high risk groups as an adjuvant therapy.
Algorithm for treatment of patients with gastrointestinal stromal tumor (GIST):
Which of the following options is the best management of a low-grade gastric lymphoma of the gastric antrum?
Low-grade mucosa-associated lymphoid tissue (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 are eradicated and the gastritis improves, the lowgrade MALT lymphoma often disappears. Thus, low-grade MALT lymphoma is not a surgical lesion.
Algorithm for gastric lymphoma treatment:
MALT= mucosa-associated lymphoid tissue.
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