Carcinoid of the Operated Stomach: Difficulties in Diagnosis

Gastric neuroendocrine tumors commonly called carcinoids arise from enterochromaffin cells of the stomach and are rare. Recently, their incidence has increased, which may be due to the improvement of diagnostic and therapeutic capabilities. The article describes a rare clinical case of gastric carcinoid 23 years after surgical removal of gastric cardia cancer.

Extirpation of the stump of the operated stomach for cancer

The issue of cancer of the stump of a previously resected stomach is insufficiently covered in the literature, and operations on this matter are performed very rarely. So, according to A. V. Melnikov (1960), out of 22 operations performed by domestic surgeons in this regard, there were 18 extirpations of the stump. The nature of the 4 operations is not specified.

To X-ray diagnostics of malignant neoplasms in patients with operated stomach

The decisive method for the treatment of malignant neoplasms of the stomach is surgical intervention. The successes achieved in this direction are limited mainly to surgery for primary cancer of the stomach. Patients with recurrent tumors in the stomach stump, as well as with secondary malignant neoplasms in this area after surgery for peptic ulcer, polyps and other diseases, were considered doomed and hopeless until recently.

Immediate and long-term results of proximal gastric resection depending on the methods of the digestive tract continuity restoring

Proximal gastric resection (PGR) is still one of the most difficult and dangerous surgical interventions, and it is the only method of curative treatment of diseases of the cardiac part of the stomach in many cases. 5 types of gastrointestinal reconstruction are mainly performed after PRG: submerged rectal esophagogastroanastomosis, antireflux interposition of the jejunal segment, interposition of the jejunal segment of the jejunal pocket, interposition of the jejunal segment as a double tract and reconstruction with the formation of a gastric tube. Modern literature includes many works devoted to the development of methods of physiological reconstruction after subtotal and total removal of the stomach; however, none of the existing methods is recognized as optimal. Among the main indicators characterizing the effectiveness of PGR are the frequency and severity of the development of a large group of functional disorders, characterized as «diseases of the operated stomach», or «post-gastro-resection disorders», which significantly worsen the quality of life (QOL) and reduce the working capacity, which causes disability of the operated patients Assessment of QoL after surgery for diseases of the cardiac stomach is a fundamentally important component of monitoring the effectiveness of treatment and, therefore, allows one to determine the indications for certain types of interventions. The available world scientific literature does not provide convincing data on the assessment of QOL in patients after proximal resection for cardiac part of the stomach diseases, since there are no clear criteria for its assessment depending on the chosen methods and methods of reconstruction of gastrointestinal tract (GIT). In this regard, there is a need for further study of proximal resection with reconstruction of the gastrointestinal tract in surgical diseases of the cardiac part of the stomach on the basis of analysis of immediate and long-term results, as well as the quality of life of patients who underwent these surgical interventions.

EFFICACY OF GASTRODUODENAL ANASTOMOSIS IN SURGERY OF DISTAL STOMACH CANCER: FROM PAST TO PRESENT

When comparing the results of surgical interventions in the modifications of Billroth-I and Billroth-II concerning carcinoma there are no significant differences both in immediate and in long-term results of treatment. At the same time the functional results of interventions and quality of life of patients are better after reconstruction of the digestive tract with the help of gastroduodenal anastomosis. Gastric stump cancer is more often occur after Billroth-II surgery. The main cause of the development of carcinoma in this case is the appearance of atrophic gastritis as a result of denervation of the organ and the transfer of bile to the operated stomach.

Reconstructive surgery of the operated stomach

The monograph formulated the concept of physiological reconstruction of the digestive tract during repeated operations on the stomach. The experience of surgical treatment of patients with diseases of the operated stomach and recurrent gastric cancer of the Department of reconstructive surgery of the esophagus and stomach Of the national medical research center of surgery named after A. V. Vishnevsky is presented. The immediate and long-term results of the original operations selected individually are highlighted. Special attention is paid to the study of motor and evacuation function of the gastrointestinal tract, to identify the frequency and severity of postgastrectomy and postgastresection syndromes after reconstructive interventions. For students and teachers, as well as anyone interested in the problems of gastric surgery.

Chronic gastritis and carcinogenesis issues

Risk factors contributing to the transformation of chronic atrophic gastritis into gastric cancer are analyzed. Detection and monitoring of patients with precancerous conditions/lesions (precancerous changes), proper screening of H. pylori make early diagnosis of gastric cancer real. Features of precancerous conditions are given in order of increasing risk of developing gastric cancer. Adenomatous polyps of the stomach take the first place. Subsequent precancerous conditions include: cancer of the operated stomach, Menetria disease (hypertrophic gastropathy), B12-deficient anemia, and gastric ulcer. A definition of intestinal metaplasia subtypes is proposed as a risk factor for gastric cancer, dividing into complete and incomplete one, taking into account reduction in the expression of gastric mucins MUC1, MUC5AC and MUC6. Currently, the development of gastric cancer (mainly of the “intestinal type”) is considered as a multistage process involving the sequence of mucosal change, such as chronic inflammation, atrophy, intestinal metaplasia, dysplasia and adenocarcinoma. Role of the organism’s genetic susceptibility to H. pylori infection, factors of pathogenicity contributing to epithelial metaplasia, are analyzed. Role of Toll-like type 4 receptors (TLR4) involved in the recognition of H. pylori is clarified. It is with this type of receptors that the development of an excessive immune response of the host is associated, resulting in damage to the mucous membrane in H. pylori-infected individuals. In particular, carriers of TLR4+896A> G polymorphism have a more severe atrophy of the stomach and degree of inflammation, as well as an increased risk of non-cardiac gastric cancer.

Reconstructive Gastroplasty in Postgastrectomy Surgery

Objective. The compensation of digestive disorder in patients who already had gastric operation by using jejuno(colo)gastroplasty at re-reconstruction of the digestive tract.Methods. During 2012-17 in Vishnevsky surgery institute 33 repeated operation were conducted on the patients who had already had resection and antireflux gastric operations. As a repeated operation was conducted jejunogastroplasty in 31 (93,9%) cases, after distal gastrectomy - 8 (24,3%) from them; after gastric stump removal - 7 (21,2%), after еsophagojejuno anastomosis resection - в 2 (6,1%). Also 3 (9,1%) patients were operated on using interposition of the discharge loop into the duodenum: 2 - after gastrectomy with Braun and Roux-en-Y и 1 - after Distal gastrectomy, Hoffmeister. Esophagogastro anastomosis resection; jejunogastroplasty in Merendino-Dillard were conducted on 11 (33,3%) patients. A segment of transverse colon as a plastic material was used on 2 (6,1%) patients: у 1 - after gastric stump removal, у 1 - after еsophagojejuno anastomosis resection.Results. In the early postoperative period 2 (6,1%) patients had surgical complications: one had Partial esophagojejunо anastomosis leakage, the other - under diaphragmatic abscess. One fatal case from progressing multiple organ failure was recorded in the first 24 hours. By the end of the research 28 (84,8%) of 33 patients stayed under the surveillance. The examining of the patients revealed good results after the operation of 21 (75,0%) patients and satisfactory results after the operation of 7 (25,0%) patients. Conclusion. We believe that principles proposed of physiological reconstruction of the digestive tract are universal for primary gastric interventions as well as for repeated ones. It is worth noting that the repeated operations don’t always fully remove clinical manifestations diseases of the operated stomach but significantly decrease their severity by strengthening the patients physically by restoration of physiological passage of food and the expansion of the nutrition.