The Pyloric Sphincteric Cylinder in Health and Disease

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Chapter 33 (page 164)

According to Öhman et al. (l972) gastric carcinomas could be graded histologically into the following types: (1) highly differentiated adenocarcinoma; (2) moderately differentiated adenocarcinoma; (3) poorly differentiated adenocarcinoma; (4) undifferentiated or expansive carcinoma; (5) linitis plastica; (6) gelatinous type. The highly differentiated adenocarcinomas had the best prognosis while there was no prognostic difference between the moderately and poorly differentiated and undifferentiated types. The prognostic significance of the degree of differentiation was probably linked to dissimilarities in longitudinal growth along the wall and the occurrence of lymph node metastases. Linitis plastica, which was also undifferentiated, spread in a different, infiltrative manner and had the worst prognosis of all. While all gastric carcinomas contained some amount of mucus, abundant mucinous masses were present in gelatinous carcinoma.

Ming (l973) reiterated that gastric carcinomas are highly infiltrative tumors, extending rapidly to the serosa. From here tumor cells may implant on other parts of the peritoneum; lymphatic and vascular spread is common. On gross examination of his cases the lesion often appeared to end sharply at the gastroduodenal junction, but it had been documented repeatedly that tumor extension into the duodenum was not uncommon. In many of those cases the duodenal invasion was mostly subserosal and the mucosa was not involved. The reason for the latter phenomenon was not known. Intramural spread of a highly infiltrative tumor to other parts of the small bowel and colon as reported by Fernet et al. (l965) appeared to be very rare.

Koehler et al. (l977) reviewed 111 consecutive cases with gastric adenocarcinoma. Spread of tumor to the duodenum was evident on gross inspection of the resected specimens in 7 cases (6 percent). In 6 patients (5 percent) radiographic abnormalities of the duodenum due to the transpyloric extension of gastric carcinoma were evident. (In the other case gastric outlet obstruction prevented radiological evaluation of the duodenum). In 2 patients without duodenal invasion, radiographic deformities of the duodenal bulb were due to inflammatory changes adjacent to the gastric tumor, and in one case the duodenal bulb was deformed due to metastatically enlarged adjacent lymph nodes. Microscopically the duodenum was involved in 20 cases (18 percent). Tumor cells were noted predominantly in the muscular and submucous layers of the duodenum, but mucosal invasion was noted occasionally. From the literature they concluded that in as many as half the cases with duodenal involvement, the tumor extended no more than 1.0 cm beyond the pylorus.

Joffe et al. (l977) described 4 cases with intraluminal filling defects of the duodenal bulb secondary to transpyloric prolapse of polypoid gastric carcinomas. It was pointed out that primary adenocarcinoma of the duodenum practically never arose in the bulb, and that intraluminal filling defects of the duodenum due to malignant lymphoma or metastatic malignancy were rare. Radiologically the cases had to be differentiated from prolapse of gastric mucosa (Chap. 38).

Present Investigations

Patients and Methods

In an effort to further elucidate duodenal spread and some other features of pyloric carcinoma, we did a retrospective study of 50 consecutive cases encountered in the radiological department over a period of 3 years. These patients had been referred for examination from the out-patient department during the ordinary course of events. At the time a barium radiographic study was the primary investigation for suspected gastric carcinoma. Because of the heavy work load and other reasons endoscopy was generally reserved for conditions such as haematemesis and radiologically negative dyspepsia, and for obtaining biopsies in cases of gastric ulceration. Moreover endoscopy was considered to have certain shortcomings in the diagnosis of gastric malignancy, especially in the pyloric region. Whereas the oral border of the lesion is usually clearly visualized endoscopically, narrowing and deformity may preclude passage of the instrument and the full extent of the lesion, as well as possible duodenal involvement, may not be evident. The barium suspension, on the other hand, usually traverses most narrowings to enter the duodenum, and the aboral border of the lesion may be seen.

Pyloric carcinoma was defined, somewhat arbitrarily, as a gastric carcinoma which, at the radiographic investigation, was seen to extend to the pyloric ring or to within 2.0 cm of the ring. Cases in which the aboral border of the lesion was more than 2.0 cm away from the ring were excluded. On average the duration of symptoms in these patients was from 4 to 12 months, i.e. they presented at a rather late stage of the disease; radiologically the lesions left little room for doubt. Cases of early gastric carcinoma, in which the lesion is limited to the mucosa, were not encountered, presumably because of the late presentations.

All cases were subsequently confirmed by endoscopic biopsy and/or operation, and the histology was obtained in 40 (Table 33.1). In 10 of the unresectable cases the surgeons deemed histological confirmation unnecessary. The 44 operations consisted of 24 Billroth II and 2 Billroth I partial gastrectomies, 16 palliative gastro-enterostomies and 2 exploratory laparotomies (in which widespread metastases precluded surgical palliation).

Table 33.1 Fifty cases of Pyloric Carcinoma

Radiographic examinationEndoscopic biopsyOperationHistology


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