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IntroductionEdit

This can be done for a non-pathologic reason (gastric bypass for bariatric surgery) or for the presence of an ulcer. In any case, look for pathology in the mucosa. If there is an ulcer, the major questions to be addressed are:

  • Is the ulcer benign or malignant?
  • What is the underlying reason for the ulcer?

Fresh HandlingEdit

  1. Measure - length of greater curvature, lesser curvature, esophageal and duodenal cuffs (if present), staple lines, surrounding fat, gastric wall thickness.
  2. Open specimen along the greater curvature. If by palpation there is a lesion, avoid cutting through that area. There is no need to ink (but as always, inking too much is better than inking too little!)
  3. Examine specimen after it is opened for any pathological findings, including small mucosal erosions and irregularities; also for intramural and subserosal nodules.
  4. Photograph specimen after it is opened (probably useful only if procedure was done for a specific lesion).
  5. Pin on corkboard, mucosa side up. Fix overnight.

Grossing InEdit

  1. Describe the type of resection (total or subtotal) and state the measurements.
  2. If there is an ulcer, describe its characteristics:
    1. location
    2. size (including thickness)
    3. shape (fungating, spreading, ulcerated)
    4. color
    5. appearance of ulcer margins
    6. depth of penetration
    7. presence of large vessels
    8. presence of perforation
    9. distance from both lines of resection.
  3. If there is no grossly evident lesion, check the clinical history to confirm that there is no clinical suspicion for an ulcer or something else. If not, just describe the mucosa as normal (pink-tan, velvety, with rugal folds).
  4. See sample dictation for sectioning guidelines.

Sample DictationEdit

Gastric bypassEdit

Specimen number ___ is received following formalin fixation in one container labeled with the patient's name and medical record number and designated "Stomach, sleeve gastrectomy." The tissue consists of an (oriented, unoriented) gastrectomy specimen measuring ___ x ___ x ___ cm overall, with a staple line measuring ___ cm. The serosal surface of the specimen is tan and glistening (with no lesions, with focal areas of hemorrhage). The specimen is opened to reveal x cc of (bloody material, partially digested gastric contents, brown fluid) and a pink-tan velvety mucosa with no visible ulcerations, erosions or other lesions.

Representative sections are submitted as follows:

  • 1A-1B: Representative sections of the staple line.
  • 1C-1D: Representative sections of the specimen ends.
  • 1E-1H: Representative sections of stomach.

Gastrectomy, ulcerEdit

Specimen number ___ is received (fresh, in formalin), labeled with the patient’s name and medical record number, designated (subtotal gastrectomy, total gastrectomy). It consists of a portion of (stomach, stomach and distal esophagus and/or proximal duodenum). The stomach measures ___x___x___ cm overall, with the greater curvature measuring ___ cm and the lesser curvature measuring ___ cm. The attached portion of esophagus measures ___x___x___ cm and the attached portion of duodenum measures ___x___x___ cm. The proximal and distal resection margins and deep margin are inked and the specimen is opened along the greater (or lesser) curvature to reveal an ulcer present (at the lesser curvature, greater curvature, anterior portion, or posterior portion) of the stomach that measures ___x___, that is ___ cm from the proximal margin and ___ cm from the distal margin. The ulcer is (describe shape, color, appearance of ulcer margins [flat or elevated], presence of large vessels and/or perforation of ulcer base). On cut section, the ulcer measures ___ cm in thickness and grossly appears to penetrate (up to, into, through) the muscularis propria, but is ___ cm from the deep inked serosal margin. The serosal surface appears (smooth, fibrinous, roughened with adhesions). The uninvolved gastric mucosa is (describe normal or other lesions: normal is velvety tan-pink with rugal folds; lesions may include polyps, rugal abnormalities, wall thickening) and the wall thickness measures ___ cm. The pylorus appears (normal, stenotic, ulcerated). The uninvolved duodenal mucosa is (describe normal or other lesion: normal is velvety tan-pink). The uninvolved esophageal mucosa is (describe normal or other lesion: normal is glistening, smooth, and white). The attached portion of peri-gastric adipose tissue measures ___x___x___ cm and is dissected to reveal ___ potential lymph nodes (initially sample at least three nodes; if ulcer turns out to be malignant, a complete lymph node dissection, with at least ten lymph nodes, is required). A portion of omentum (is/ is not) present and measures ___x___x___ cm and is grossly unremarkable.

SECTION KEY:

  • Representative sections of the ulcer are submitted as ___.
    • Four sections of the ulcer should be submitted: one in association with adjacent proximal gastric mucosa; one in association with adjacent distal gastric mucosa; and two full thickness sections including inked deep resection margin. Remember, one section of ulcer can sometimes show both the association with normal and level of penetration.
  • Proximal gastric resection margins from the lesser and greater curvatures, and anterior and posterior portions of stomach are submitted as ___, ___, ___, and ___, respectively.
  • One shave or perpendicular section from each of the following four areas: lesser curvature, greater curvature, anterior portion, and posterior portion of stomach. If esophagus is present, submit shaved esophageal margin as proximal resection margin.
  • Distal gastric resection margin is submitted as ___.
    • At least two representative shave or perpendicular sections of margin closest to ulcer. If duodenum is present, submit shaved duodenal margin as distal resection margin.
  • Uninvolved proximal and distal gastric mucosa submitted as ___ and ___, respectively.
    • One representative section of each.
  • Representative gastroesophageal junction and pylorus are submitted as ___ and ___, respectively.
    • One representative section of each, if present.
  • ___ potential lymph nodes submitted as ___.
  • Other mucosal abnormalities, away from the tumor, submitted as ___.

Review and SignoutEdit

Sample diagnostic linesEdit

1. Stomach, laparoscopic sleeve gastrectomy:

-Portion of stomach with gastric oxyntic-type mucosa with (scattered benign lymphoid aggregates, chronic gastritis, no specific pathologic change).

1. Stomach, gastric bypass:

-Portion of stomach, (oxyntic mucosa-lined) with no specific pathologic change, margins of resection viable.

1. Stomach, partial gastrectomy:

-Portion of stomach with ulcer and chronic gastritis, (mildly, moderately, severely) active, with (no) organisms consistent with H. pylori, no malignancy seen.

Return to Gastrointestinal Grossing

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