BENIGN Adenoma Benign stromal tumors MALIGNANT Distal gastric adenocarcinoma Diffuse carcinoma Cardiac carcinoma MALT lymphoma,

small and large cell types Sarcoma Anastomotic Leakage After a surgeon removes a portion of the stomach, she connects the remaining part of the stomach to the upper region of the small intestine, called the duodenum, with stitches. This newly created connection point is referred to as the anastomosis. If the anastomosis does not heal properly, ingested food products within the stomach or intestine can leak through this connection point into the abdominal cavity. Anastomotic leakage elevates a patient's risk of developing a severe abdominal infection called peritonitis, which can lead to abdominal bloating, stomach upset, fever, diarrhea or fatigue. Patients who develop any of these symptoms after undergoing a partial gastrectomy should contact a doctor immediately. Dumping Syndrome Dumping syndrome is a complication after partial gastrectomy that affects approximately up to 20 percent of patients treated for a stomach ulcer, Patient UK reports. This complication occurs because ingested food products pass too quickly through the stomach without being properly digested. Symptoms of dumping syndrome include weakness, headache, nausea, vomiting, sweating, flushing and heart rate irregularities. Patients typically experience dumping syndrome symptoms within 30 to 180 minutes after eating a meal. Vitamin or Iron Deficiency A partial gastrectomy can negatively affect the way nutrients and vitamins are absorbed from ingested foods. Consequently, patients can develop unusually low levels of vitamins or iron within the body. Low iron levels can result in anemia, a condition characterized by abnormally low red blood cell levels. Affected patients can experience excessive fatigue, increased sensitivity to cold, dizziness or pale skin. Patients should talk with a doctor regarding what dietary guidelines to follow after undergoing a partial gastrectomy to help limit nutritional deficiency complications. Stomach Ulcers Patients can develop recurrent stomach ulcers as a complication following partial gastrectomy surgery, MDGuidelines warns. A stomach or peptic ulcer is an open skin lesion that develops within the tissue that lines the stomach. Symptoms of a stomach ulcer include chronic stomach pain, stool discoloration, nausea, vomiting, decreased appetite and weight loss. Patients should discuss these symptoms with a physician if they occur. Infection or Bleeding A partial gastrectomy increases a patient's risk of developing infection or bleeding complications after surgery, the Baylor College of Medicine reports. Such complications can cause increased stomach pain, fever, abdominal tenderness or incision site drainage. Affected patients may require additional antibiotic medication or surgical intervention to resolve infection or bleeding complications after partial gastrectomy. Common complications include wound infection, leakage at the site where the stomach is joined to the intestine (anastomosis), partial lung collapse (atelectasis), and bleeding. Less common complications include shock (from bleeding) or cardiac arrest. Late complications include recurrent ulcers, diarrhea (from sugar and carbohydrate intolerance), and iron deficiency anemia. Depending on the extent of surgery, ongoing

complications may include backward flow of stomach fluids (reflux), malnutrition from reduced food intake, weight loss, and stomach contents moving too rapidly into the small intestine (dumping syndrome). Collectively, the late complications and several other rarer conditions are referred to as postgastrectomy syndromes. They can occur in up to 25% of individuals undergoing the procedures. These conditions and others such as diarrhea, abdominal cramping, nausea, and weakness can complicate return to work and require accommodations. A laparotomy is a surgical procedure involving a large incision through theabdominal wall to gain access into the abdominal cavity. It is also known as coeliotomy Goal Restore circulating volume Procedure Insert widebore peripheral cannulae Give adequate volumes of warmed crystalloid, ?colloid, blood Aim to maintain normal blood pressure and urine output >30 ml h 1 Clinician in charge Duty anaesthetist Blood bank Duty haematologist Early surgical or obstetric intervention Interventional radiology Comments 14 G or larger Monitor central venous pressure Blood loss is often underestimated Refer to Advanced Trauma Life Support guidelines Keep patient warm Nominated coordinator should take responsibility for communication and documentation

Contact key personnel

Arrest bleeding

Request laboratory investigations

Request suitable red cells

Take samples at earliest opportunity FBC, PT, APTT, fibrinogen; bloodbank sample, biochemical profile, blood gases or as results may be affected by colloid pulse oximetry infusion Misidentification is commonest Ensure correct sample identity transfusion risk Repeat FBC, PT, APTT, fibrinogen every May need to give components before 4 h or after 1/3 blood volume replacement results available Repeat after blood component infusion Rh positive is acceptable if patient is male or Uncrossmatched group O Rh negative In extreme emergency postmenopausal female No more than 2 units Laboratory will complete crossmatch Uncrossmatched ABO groupspecific after issue When blood group known Further crossmatch not required after replacement of 1 blood volume (810 units) Fully crossmatched If irregular antibodies present When time permits

Request platelets

Use blood warmer and/or rapid infusion device. Employ blood salvage if available and appropriate Allow for delivery time from blood centre Anticipate platelet count <50109 litre 1 after 2 blood volume replacement

Request FFP (1215 ml kg1 body weight=1 litre or 4 units for an adult) Request cryoprecipitate (11.5 packs/10 kg body weight)

Aim for PT and APTT <1.5 control mean

Bloodwarmer indicated if flow rate >50 ml kg1 h1 in adult Salvage contraindicated if wound heavily contaminated Target platelet count: >100109 litre1 for multiple/CNS trauma or if platelet function abnormal >50109 litre1 for other situations PT and APTT >1.5 control mean correlates with

Allow for 30 min thawing time Replace fibrinogen and factor VIII

increased surgical bleeding Fibrinogen <0.5 strongly associated with microvascular bleeding Fibrinogen deficiency develops early when plasmapoor red blood cells used for replacement Shock, hypothermia, acidosis leading to risk of DIC Mortality from DIC is high

Aim for fibrinogen >1.0 g litre1 Allow for delivery time plus 30 min thawing time Suspect DIC Treat underlying cause if possible

Laparotomy procedure A laparotomy is performed under general anaesthesia. The surgeon makes a single cut through the skin and muscle of the abdomen, so that the underlying organs can be clearly viewed. The exposed organs are then carefully examined. Once diagnosed, the problem may be fixed on the spot (for example, a perforated bowel may be repaired). In other cases, a second operation may be needed. Once the laparotomy is complete, the muscle of the abdominal wall and the overlying skin are sutured (sewn) closed. Immediately after the operation After the operation, you can expect: Your temperature, pulse, respiration, blood pressure and wound site are carefully monitored. You may have a drain inserted at the wound site. A small tube may have been passed through your nose and into your stomach to help drain stomach secretions for a day or two. This rests your digestive tract as it heals. A urinary catheter may be inserted to drain off urine. You are given intravenous fluids (directly into the vein), as you may not be allowed to eat for a few days. Pain relief should be given regularly, as ordered by your doctor, to keep you comfortable. As soon as possible, you are encouraged to do your deep breathing and leg exercises. You are assisted out of bed the day after the operation (all going well). Early walking is important, as it reduces the risks of blood clots and chest infections. You are given daily wound care and observation, along with advice on caring for your wound at home. Medication is given to you on discharge. Possible complications Possible complications of laparotomy include: Haemorrhage (bleeding)

Infection Damage to internal organs Formation of internal scar tissue (adhesions) Bowel blockages or abdominal pain, which may be caused by adhesions.

Immunohistochemistry or IHC refers to the process of detecting antigens (e.g., proteins) in cells of a tissue section by exploiting the principle of antibodies binding specifically toantigens in biological tissues.[1] IHC takes its name from the roots "immuno," in reference to antibodies used in the procedure, and "histo," meaning tissue (compare toimmunocytochemistry). Immunohistochemical staining is widely used in the diagnosis of abnormal cells such as those found in cancerous tumors. Specific molecular markers are characteristic of particular cellular events such as proliferation or cell death (apoptosis). IHC is also widely used in basic research to understand the distribution and localization of biomarkers and differentially expressed proteins in different parts of a biological tissue. Visualising an antibody-antigen interaction can be accomplished in a number of ways. In the most common instance, an antibody is conjugated to an enzyme, such as peroxidase, that can catalyse a colour-producing reaction (see immunoperoxidase staining). Alternatively, the antibody can also be tagged to a fluorophore, such as fluorescein orrhodamine (see immunofluorescence). While using the right antibodies to target the correct antigens and amplify the signal is important for visualization, complete preparation of the sample is critical to maintain cell morphology, tissue architecture and the antigenicity of target epitopes. This requires proper tissue collection, fixation and sectioning. Paraformaldehyde is usually used with fixation. Depending on the purpose and the thickness of the experimental sample, either thin (about 440 m) sections are sliced from the tissue of interest, or if the tissue is not very thick and is penetrable it is used whole. The slicing is usually accomplished through the use of a microtome, and slices are mounted on slides. "Free-floating IHC" uses slices that are not mounted, these slices are normally produced using a vibrating microtome. Because of the method of fixation and tissue preservation, the sample may require additional steps to make the epitopes available for antibody binding, including deparaffinization and antigen retrieval (microwave method, enzyme method, hot incubation method); these steps often makes the difference between staining and no staining. Additionally, depending on the tissue type and the method of antigen detection, endogenous biotin or enzymes may need to be blocked or quenched, respectively, prior to antibody staining. Unlike immunocytochemistry, the tissue does not need to be permeabilized because this has already been accomplished by the microtome blade during sample preparation. Detergents like Triton X-100 are generally used in immunohistochemistry to reduce surface tension, allowing less reagent to be used to achieve better and more even coverage of the sample. Although antibodies show preferential avidity for specific epitopes, they may partially or weakly bind to sites on nonspecific proteins (also called reactive sites) that are similar to the cognate binding sites on the target antigen. In the context of antibody-mediated antigen detection, nonspecific binding causes high background staining that can mask the detection of the target antigen. To reduce background staining in IHC, ICC and any other immunostaining application, the samples are incubated with a buffer that blocks the reactive sites to which the primary or secondary antibodies may otherwise bind. Common blocking buffers include normal serum, non-fat dry milk, BSA or gelatin, and commercial blocking buffers with proprietary formulations are available for greater efficiency.

In immunohistochemical techniques, there are several steps prior to the final staining of the tissue antigen, and many potential problems affect the outcome of the procedure. The major problem areas in IHC staining include strong background staining, weak target antigen staining and autofluorescence. Endogenous biotin or reporter enzymes or primary/secondary antibody cross-reactivity are common causes of strong background staining, while weak staining may be caused by poor enzyme activity or primary antibody potency. Furthermore, autofluorescence may be due to the nature of the tissue or the fixation method. These aspects of IHC tissue prep and antibody staining must be systematically addressed to identify and overcome staining issues. IHC is an excellent detection technique and has the tremendous advantage of being able to show exactly where a given protein is located within the tissue examined. It is also an effective way to examine the tissues .This has made it a widely used technique in theneurosciences, enabling researchers to examine protein expression within specific brain structures. Its major disadvantage is that, unlike immunoblotting techniques where staining is checked against a molecular weight ladder, it is impossible to show in IHC that the staining corresponds with the protein of interest. For this reason, primary antibodies must be well-validated in a Western Blot or similar procedure. The technique is even more widely used in diagnostic surgical pathology for typing tumors (e.g. immunostaining for e-cadherin to differentiate between DCIS (ductal carcinoma in situ: stains positive) and LCIS (lobular carcinoma in situ: does not stain positive)[2]).

Carcinoembryonic antigen (CEA): used for identification of adenocarcinomas. Not specific for site. Cytokeratins: used for identification of carcinomas but may also be expressed in some sarcomas.[3] CD15 and CD30 : used for Hodgkin's disease Alpha fetoprotein: for yolk sac tumors and hepatocellular carcinoma CD117 (KIT): for gastrointestinal stromal tumors (GIST) CD10 (CALLA): for renal cell carcinoma and acute lymphoblastic leukemia Prostate specific antigen (PSA): for prostate cancer estrogens and progesterone staining for tumour identification Identification of B-cell lymphomas using CD20 Identification of T-cell lymphomas using CD3