SAKSHI

Grossing of Esophagus & Stomach

Normal Anatomy•begins at the level of cricoid cartilage •measures approx 25 cm in length and 2 cm in diameter (adult).•On ENDOSCOPY : from incisors – (16cm distal)•35-40 cm GEJ

Gross Examination and Tissue Handling

1. Endoscopic biopsies2. Endoscopic mucosal resection (EMR)- for

the treatment of Barrett's esophagus– associated high-grade dysplasia (HGD) and superficial carcinoma as determined by endoscopic ultrasound.

3. Esophagectomy or Esophagogastrectomy: - the specimen is opened longitudinally The esophagus and the attached portion of the stomach

are then measured for - length, - circumference, and - wall thicknessThe size and appearance – - polypoid, - fungating, - ulcerated, - or diffuse thickening with narrowing of the lumenIts relationship to the - GE junction and - distance from the proximal and distal margins

Esophagectomy

•Upper third – deep cervical nodes.● Middle third – superior and posterior mediastinal nodes.● Lower third – nodes along the left gastric blood vessels and the coeliac n

On gross Barrett's mucosa can be patchy and is recognized as salmon colored and finely granular, similar to gastric mucosa,

In contrast to the gray-white, smooth, and glistening squamous cell lining of the normal esophagus

The grossly identified lesion is then longitudinally cross-sectioned to examine the depth of invasion

Choice of surgical procedure in oesophageal neoplasia

Proximal 1/3 tumours - Pharyngo-oesophagectomy.Middle 1/3 tumours - Ivor Lewis technique

- Thoracoabdominal oesophagectomy- Two field transhiatal oesophagectomy

Lower 1/3 tumours - Ivor Lewis technique- Thoracoabdominal oesophagectomy- Transhiatal oesophagectomy

Barrett’s - Transhiatal oesophagectomy

Surgeries

5 cm longitudinal margin of clearance with adenocarcinoma

and 10 cm for squamous carcinoma. A) Ivor Lewis technique: upper abdominal and

right thoracotomy incisions.

The proximal stomach is divided and the oesophagus is transected proximal to the tumour.

Esophagogastric anastomosis is done in chest.

Thoracoabdominal oesophagectomy

continuous incision extending from the midline of the upper abdomen running obliquely across the rib margin and posterolateral aspect of the chest wall is made

potential enbloc resection of the oesophagus, stomach, gastric nodes and, if required, the spleen anddistal pancreas.

An oesophagojejunal or oesophagogastric anastomosis is fashioned in theneck.

Transhiatal oesophagectomy

‘Two-field approach’ – the entire oesophagus and stomach is mobilised via upper abdominal and oblique neck incisions.

The cervical oesophagus is divided and anastomosed to stomach, which had been mobilised and raised high into the posterior mediastinum.

Distal oesophagectomy with proximal gastrectomy

for distal oesophageal/junctional tumours. Only an upper abdominal incision is used,

with the distal oesophagus being mobilised and an oesophagogastric anastomosis

fashioned in the chest.

Stomach Grossing Specimen Handling

Biopsy:Fragments, non-orientated: Fragments, orientated:Polyp – Non-orientated fragments:snare specimens:Wedge biopsyNeedle core biopsy:

Resection Specimens

Before fixation assess the tumour – for location, margin clearance as it shrinks

Fixation: Adequate fixation of a cleaned, opened specimen requires 36–48 hours immersion in formalin

Margins: Longitudinal margins:

Cardia: mucin-secreting cells.Fundus/body: parietal cells (acid), chief cells

(pepsin) and scattered endocrine cells.Antrum/pylorus: endocrine (mostly gastrin G

cells) and mucin-secreting cells.

Lymphatics