Preoperative Workup

After confirmation of the diagnosis of gastric AC, an accurate preoperative work-up is needed to guide the patient down the appropriate treatment algorithm (Figure 34-1). Endoscopic ultrasound (EUS) is the most accurate mode to determine T-stage. Additionally, perigastric lymph nodes and adjacent organ and vascular involvement can be assessed. A computed tomography (CT) scan of the abdomen provides information regarding extragastric disease, which most commonly occurs in the peritoneal cavity or liver. If the lesion was excised at endoscopy and found to be an early T1 or T2 cancer, EUS and CT scans are not necessary, and the patient can be prepared for definitive treatment. For T3 and T4 lesions, a staging laparoscopy should be performed due to the increased chance of metastatic or locally, advanced disease. If metastases are seen on

Work-up

Diagnosis confirmed

T1, T2

EUS

T3, T4

laparoscopy

Consider preop chemo for T3, N any, M0 or T4, N any (potentially resectable)

laparoscopy

Consider preop chemo for T3, N any, M0 or T4, N any (potentially resectable)

No metastasis

metastasis

—l

1

OPERATION

palliation

FIGURE 34-1. Treatment algorithm for patients with gastric cancer. CT = computed tomography; EUS = endoscopic ultrasound.

laparoscope then a biopsy should be taken and the patient should be referred for palliative chemotherapy. If no metastases are seen, then preoperative chemotherapy in the context of a clinical trial should be considered before definitive surgical therapy. The use of positron emission tomography scans as part of the preoperative work-up is investigational and should be evaluated in the setting of a protocol.

Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

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