الفهرس 
Surgical Anatomy of the StomachOnly 14 pages are availabe for public view
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Abstract
Stomach is the most dilated part of digestive tube, and it is situated between the end of the esophagus and the beginning of small intestine. It lies in the epigastric, umbilical, and left hypochondrial regions of the abdomen, and occupies a recess bounded by the upper abdominal viscera, and completed in front and on the left side by the anterior abdominal wall and the diaphragm.
Gastric cancer is declining in incidence but remains the number two cause of cancer death incidence in the world.
The macroscopic appearance of gastric cancer has been described according to several schemes. There is wide variation in the gross appearance of carcinoma of the stomach. Many intermediate stages exist between the two variants represented by fungating tumor growing mainly into the lumen and the flat, ulcerated and deeply invasive tumor growing through the wall of the stomach.
Early gastric cancer of the intestinal type is asymptomatic but early diffuse cancer may present with dyspepsia simulating peptic ulceration. However, curable gastric cancer has no specific features to distinguish from benign dyspepsia the early symptoms are often vague and include indigestion, malaise, early satiety, post-prandial fullness and loss of appetite. Weight loss is a significant feature of the disease but usually signifies an advanced lesion that has involved the muscular coat of the stomach or beyond. The symptoms may respond to the treatment with antacids and H2 receptor blockers/PPIs.
Flexible fiberoptic endoscopy is the most accurate method of diagnosing gastric cancer currently available. Use of the technique has evolved to the point that in experienced hands, detection of non-ulcerative and even gastritis-like malignant lesions is not uncommon.
The use of mass upper gastrointestinal surveys and the gastrocamera has made possible earlier detection of lesions than was possible with the usual methods.
Treatment of gastric cancer depends on three main modalities, which are surgery, radiotherapy and chemotherapy. The choice of individual treatment and appropriate combination of treatments depends on the stage of disease. Surgical resection is the only potentially curative treatment modality.
The extent of surgery is being largely dependent on the extent of tumor and status of the rest of the mucosa. Surgery is effective when gastric cancers are confined to the stomach wall but surgical cures are uncommon in the presence of regional lymph node involvement or extra gastric tumor extension. The selection of an operative procedure must take into account the stage of disease, the location and size of the primary tumor, possible antecedent surgery for benign disease, and the overall medical status of the patients.
There is no support from randomized studies for routine D2 dissection, although it is suggested on the basis mainly on cohort studies that in stage II and III patients, a more extensive lymph node dissection might be associated with prolonged cancer free survival. A D2 resection is therefore proposed for fit patients provided the surgeon is well experienced with this procedure. If a total gastrectomy is performed, a reconstruction that includes a jejunal pouch should be considered in patients with favorable tumor stages. For cancer of the gastric cardia, a total gastrectomy with high anastomosis, a thoracoabdominal gastro esophageal resection, or an esophagectomy without thoracotomy could be used. There is insufficient evidence to support the routine use of adjuvant chemotherapy in patients operated on for gastric cancer. In some patients, chemotherapy could be of significant palliative value.
Endoscopic mucosal resection has been advocated for early gastric cancers, those that are superficial and confined to the mucosa without evidence of nodal or distant metastases, with differentiated tumors that are slightly raised and less than 2 cm in diameter, or in differentiated tumors that are ulcerated and less than 1 cm in diameter.