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Danilo Nagib Salomão Paulo - One of the best experts on this subject based on the ideXlab platform.
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Effects of inferior splenic lobe pole fixation and Gastrosplenic peritoneal membrane section on the vitality of the remanent of subtotal splenectomy in rats
Acta cirurgica brasileira, 2015Co-Authors: Fernanda Alves Mendonça, Felipe Poubel Timm Do Carmo, Louise Goncalves Paris, Marya Duarte Pagotte, Fernanda Lube Antunes Pereira, Paula Vieira Teixeira Vidigal, Danilo Nagib Salomão Paulo, Tarcizo Afonso NunesAbstract:PURPOSE: To investigate the vitality of the spleen lower pole after subtotal splenectomy with suture to the stomach and after posterior peritoneal gastro-splenic membrane section, using macro and microscopic evaluations. METHODS: Sixty Wistar rats were used in this study and were randomly distributed in the three groups: Group 1: (n=20), subtotal splenectomy with lower pole preservation, Group 2: (n=20) subtotal splenectomy with lower pole preservation and suture to the stomach, Group 3: subtotal splenectomy with lower pole preservation and posterior peritoneal Gastrosplenic Ligament section. The animals were sacrificed 45 days after the surgery and the spleen lower poles were removed for macroscopic and microscopic examination. RESULTS: All animals in this series survived. No macroscopic differences were encountered between the groups. Microscopic evaluation observed statistic difference concerning fibrosis between group 1 and 3 (p≤0.05), but the analysis for necrosis and inflammation presented no differences. CONCLUSION: Vitality of the spleen lower pole after subtotal splenectomy is minimally modified when it is fixed to the stomach or when the posterior peritoneal Gastrosplenic Ligament is resected.
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Subtotal splenectomy preserving the lower pole in rats: technical, morphological and functional aspects
Acta cirurgica brasileira, 2006Co-Authors: Danilo Nagib Salomão Paulo, Isabel Cristina Andreatta Lemos Paulo, Mitre Kalil, Paulo Roberto Merçon De Vargas, Alcino Lázaro Da Silva, João Florêncio De Abreu Baptista, Alvino Jorge GuerraAbstract:PURPOSE: To assess the possibility of preserving the lower pole of the spleen, supplied by the inferior lobar vessels and segmental vessels, or by vessels of the Gastrosplenic Ligament, in subtotal splenectomy; to study the viability and function of the lower pole of the spleen. METHODS: Thirty-six male Wistar rats were used in this study. Said animals weighed 273-390 g ( 355.2 ± 30.5 g ), and were randomly distributed into three groups. Group 1 comprised ten animals which were submitted to exploratory laparotomy with spleen manipulation (sham operation). Group 2 comprised 16 animals which were submitted to total splenectomy. Group 3 comprised ten animals which were submitted to subtotal splenectomy, preserving the lower pole of the spleen. Blood was collected from all animals before and 90 days after surgery to measure the levels of cholesterol and triglycerides. The animals were sacrificed 90 days after surgery. Spleens and remaining spleens were removed for macroscopic and microscopic examination. RESULTS: Surgery was performed with no complications in all groups. Six animals died in group 2. Spleens of groups 1 and 2, and lower poles of group 3 were macroscopically viable. Apparent white pulp hyperplasia was observed in group 1. In group 3, slight inflammation and capsular fibrosis were observed at the incision site, as well as diffuse hemosiderosis in the red pulp. Average mass of remaining spleen was 35.84% ± 4.31%. No significant difference was observed between preoperative and late postoperative lipid levels in groups 1 and 3 (p > 0.05). Late postoperative lipid levels significantly increased in group 2. CONCLUSIONS: Preservation of the lower pole of the spleen (supplied by Gastrosplenic vessels or inferior lobar vessels and segmental vessels) was possible with subtotal splenectomy. The lower pole was macroscopically and microscopically viable in all cases. Subtotal splenectomy preserving the lower pole prevented changes in lipid levels, which were observed in rats submitted to total splenectomy. Plasma lipid levels in rats submitted to subtotal splenectomy were similar to those observed in sham operated rats.
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Subtotal splenectomy preserving the lower pole in rats: technical, morphological and functional aspects Esplenectomia subtotal com preservação do pólo inferior em ratos: aspectos técnicos, morfológicos e funcionais
Sociedade Brasileira para o Desenvolvimento da Pesquisa em Cirurgia, 2006Co-Authors: Danilo Nagib Salomão Paulo, Isabel Cristina Andreatta Lemos Paulo, Mitre Kalil, Alcino Lázaro Da Silva, João Florêncio De Abreu Baptista, Paulo Merçon Vargas, Alvino Jorge GuerraAbstract:PURPOSE: To assess the possibility of preserving the lower pole of the spleen, supplied by the inferior lobar vessels and segmental vessels, or by vessels of the Gastrosplenic Ligament, in subtotal splenectomy; to study the viability and function of the lower pole of the spleen. METHODS: Thirty-six male Wistar rats were used in this study. Said animals weighed 273-390 g ( 355.2 ± 30.5 g ), and were randomly distributed into three groups. Group 1 comprised ten animals which were submitted to exploratory laparotomy with spleen manipulation (sham operation). Group 2 comprised 16 animals which were submitted to total splenectomy. Group 3 comprised ten animals which were submitted to subtotal splenectomy, preserving the lower pole of the spleen. Blood was collected from all animals before and 90 days after surgery to measure the levels of cholesterol and triglycerides. The animals were sacrificed 90 days after surgery. Spleens and remaining spleens were removed for macroscopic and microscopic examination. RESULTS: Surgery was performed with no complications in all groups. Six animals died in group 2. Spleens of groups 1 and 2, and lower poles of group 3 were macroscopically viable. Apparent white pulp hyperplasia was observed in group 1. In group 3, slight inflammation and capsular fibrosis were observed at the incision site, as well as diffuse hemosiderosis in the red pulp. Average mass of remaining spleen was 35.84% ± 4.31%. No significant difference was observed between preoperative and late postoperative lipid levels in groups 1 and 3 (p > 0.05). Late postoperative lipid levels significantly increased in group 2. CONCLUSIONS: Preservation of the lower pole of the spleen (supplied by Gastrosplenic vessels or inferior lobar vessels and segmental vessels) was possible with subtotal splenectomy. The lower pole was macroscopically and microscopically viable in all cases. Subtotal splenectomy preserving the lower pole prevented changes in lipid levels, which were observed in rats submitted to total splenectomy. Plasma lipid levels in rats submitted to subtotal splenectomy were similar to those observed in sham operated rats.OBJETIVO: Avaliar a exequibilidade de preservação do pólo inferior suprido por vasos lobares inferiores e segmentares ou por vasos no Ligamento esplenogástrico, na esplenectomia subtotal, e estudar a viabilidade e a função desse pólo. MÉTODOS: Foram utilizados 36 ratos machos, Wistar, com peso entre 273 gramas e 390 gramas (M.A 355,2 ±30,5), distribuídos aleatoriamente em 3 grupos : grupo 1- 10 animais submetidos à laparotomia com manipulação do baço (operação simulada); grupo 2- 16 animais submetidos à esplenectomia total ; grupo 3- 10 animais submetidos à esplenectomia subtotal com preservação do pólo inferior. Em todos os animais foi colhido sangue no pré-operatório e no 90º P.O para dosagem do colesterol e frações e triglicérides. Os animais foram mortos após 90 dias e o baço e o remanescente esplênico foram retirados para estudo macro e microscópico. RESULTADOS: As operações nos três grupos foram realizadas sem dificuldades. Houve 6 óbitos no grupo da esplenectomia total. Os baços dos grupos 1 e 2 e os pólos inferiores do grupo 3 estavam macroscopicamente viáveis. Houve uma aparente hiperplasia da polpa branca no grupo simulação O pólo inferior apresentou áreas discretas de inflamação e fibrose capsular na área da incisão e hemossiderose difusa na polpa vermelha. O percentual médio de massa remanescente do pólo inferior foi 35,84% ± 4,31%. Não houve alterações significantes nos níveis de colesterol e frações e triglicérides no pós-operatório tardio em relação ao pré-operatório (P>0,05) nos grupos 1 e 3. No grupo 2 houve aumento significante do colesterol e frações e triglicérides no pós-operatório tardio. CONCLUSÕES: A preservação do pólo inferior suprido por vasos lobares inferiores e segmentares ou vasos no Ligamento esplenogástrico foi exeqüível na esplenectomia subtotal. Esse pólo manteve-se macro e microscopicamente viável em todos os casos. A esplenectomia subtotal com preservação do pólo inferior previne contra as alterações dos níveis de lípides plasmáticos observadas em ratos submetidos à esplenectomia total, e permite a manutenção dos níveis de lípides semelhantes aos do grupo simulação
Jun Hong Lee - One of the best experts on this subject based on the ideXlab platform.
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Hepatobiliary and pancreatic: Torsion of an accessory spleen
Journal of gastroenterology and hepatology, 2009Co-Authors: Ti Kim, J K Kim, Mun-soo Park, Jun Hong LeeAbstract:A 24-year-old man was investigated because of a 3-day history of epigastric pain that was accompanied by nausea and vomiting. Blood tests revealed an elevated white cell count (13.2 ¥ 10 9 /l) and a mild elevation of erythrocyte sedimentation rate (27 mm/hr) and C-reactive protein (18 mg/dl). An ultrasound (US) study revealed a homogeneous hypoechoic mass in the left upper abdomen with an internal tubular anechoic structure. The tubular structure was thought to be a blood vessel but there was no blood flow on a Doppler study. A contrast-enhanced computed tomography (CT) scan showed an ovoid mass, 8 cm in diameter, in the left upper abdomen that was adjacent to the anterior aspect of the distal transverse colon (Figure 1). The mass was clearly separate from a normal spleen, left kidney and left adrenal gland. The mass did not show contrast-enhancement apart from a small wedge-shaped area in the left lateral portion. There was also a whirled tubular structure adjacent to the mass (arrow). At laparotomy, he had a violet, oval tumor under the omentum. The tumor had a twisted vascular pedicle attached to the splenic pedicle. The resected specimen is shown in Figure 2 and pathologic examination confirmed torsion and hemorrhagic infarction of an accessory spleen. In the developing embryo, the spleen arises from several small mesodermal buds in the dorsal mesogastrium. These normally coalesce to form a single organ. However, failure of coalescence can result in the formation of one or more accessory spleens. These can be identified on an US or CT scan in approximately 3%‐4% of patients. However, at postmortem examination, the frequency of accessory spleens ranges from 10%‐30%. The most common sites for accessory spleens are the splenic hilum, the Gastrosplenic Ligament and the tail of the pancreas. Most accessory spleens are asymptomatic. However, torsion may occur as described above and hyperplasia can develop after splenectomy. The latter may be clinically significant if splenectomy is performed for hematological disorders such as hereditary spherocytosis and idiopathic thrombocytopenic purpura. On contrastenhanced CT, the differential diagnosis of torsion of an accessory spleen can include hemorrhagic complications of cysts such as mesenteric cysts, intestinal duplication and pancreatic pseudocysts.
Fernanda Alves Mendonça - One of the best experts on this subject based on the ideXlab platform.
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Effects of inferior splenic lobe pole fixation and Gastrosplenic peritoneal membrane section on the vitality of the remanent of subtotal splenectomy in rats
Acta cirurgica brasileira, 2015Co-Authors: Fernanda Alves Mendonça, Felipe Poubel Timm Do Carmo, Louise Goncalves Paris, Marya Duarte Pagotte, Fernanda Lube Antunes Pereira, Paula Vieira Teixeira Vidigal, Danilo Nagib Salomão Paulo, Tarcizo Afonso NunesAbstract:PURPOSE: To investigate the vitality of the spleen lower pole after subtotal splenectomy with suture to the stomach and after posterior peritoneal gastro-splenic membrane section, using macro and microscopic evaluations. METHODS: Sixty Wistar rats were used in this study and were randomly distributed in the three groups: Group 1: (n=20), subtotal splenectomy with lower pole preservation, Group 2: (n=20) subtotal splenectomy with lower pole preservation and suture to the stomach, Group 3: subtotal splenectomy with lower pole preservation and posterior peritoneal Gastrosplenic Ligament section. The animals were sacrificed 45 days after the surgery and the spleen lower poles were removed for macroscopic and microscopic examination. RESULTS: All animals in this series survived. No macroscopic differences were encountered between the groups. Microscopic evaluation observed statistic difference concerning fibrosis between group 1 and 3 (p≤0.05), but the analysis for necrosis and inflammation presented no differences. CONCLUSION: Vitality of the spleen lower pole after subtotal splenectomy is minimally modified when it is fixed to the stomach or when the posterior peritoneal Gastrosplenic Ligament is resected.
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Efeito da fixação do polo inferior do baço e da secção da membrana peritoneal gastroesplênica na vitalidade do remanescente da esplenectomia subtotal em ratos
Universidade Federal de Minas Gerais, 2014Co-Authors: Fernanda Alves MendonçaAbstract:A esplenectomia total está sendo cada vez mais evitada, devido aos riscos advindos da ressecção completa do baço. A esplenectomia subtotal com preservação do polo inferior (ESTPI) é a técnica mais recentemente descrita com a intenção de preservar o parênquima esplênico. Objetivo: verificar a vitalidade do polo inferior do baço, após ESTPI com ou sem fixação do polo inferior ao estômago e com secção total da membrana peritoneal gastroesplênica. Método: foram utilizados 60 ratos wistar, machos, com peso entre 280 e 320 g, distribuídos randomicamente em três grupos: grupo 1 - ESTPI (n=20), grupo 2 - ESTPI com fixação do polo inferior do baço na região do corpo gástrico (n=20), grupo 3 - ESTPI com secção da membrana peritoneal gastroesplênica (n=20). No 45º dia pós-operatório extirpou-se o polo inferior do baço e avaliou-se macroscopicamente a viabilidade por meio da coloração, forma, tamanho, aspecto da superfície, tecido necrótico, fibrótico e aderências; e microscopicamente pela presença de necrose, infiltrado inflamatório, proliferação vascular e fibrose. Os cálculos estatísticos foram realizados pelo programa Biostat 5.0 e utilizados: o teste t de student, a análise de variância (ANOVA), o teste de Kruskal Wallis e o teste exato de Fisher. O valor de p0,05 foi considerado significante. Resultados: na avaliação das alterações macroscópicas do polo inferior do baço entre os três grupos, verificou-se que não houve diferença significante entre eles. Na avaliação microscópica, constatou-se que não houve diferença quanto à necrose e à inflamação, porém a fibrose foi mais frequente no grupo 3 que no grupo 1 (85% no grupo 1, 95% no grupo 2 e 80% no grupo 3) (p0,05). Conclusão: a vitalidade do polo inferior do baço após a ESTPI não é alterada pela fixação do mesmo no estômago ou quando se secciona a membrana peritoneal gastroesplênica.Procedures on the spleen has changed in the last years, and in this scope, indication for total splenectomy has been reduced. Subtotal splenectomy preserving the lower pole is the newest option for preserving spleen parenchyma. Purpose: Verify the viablility of the spleen lower pole after subtotal splenectomy with suture to the stomach and after posterior peritoneal gastroesplenic membrane resection, using macro and microscopic avaliations. Methods: Sixty Wistar rats were used in this study and were randomly distributed in the 3 groups: Group 1: (n=20), subtotal splenectomy with lower pole preservation, Group 2: (n=20) subtotal splenectomy with lower pole preservation and suture to the stomach, Group 3: subtotal splenectomy with lower pole preservationa and posterior peritoneal Ligament resection. The animals were sacrificed 45 days after the surgery and the spleen lower poles were removed for macroscopic and microscopic examination. Results: All animals in this series survived. No macroscopic diferences were encountered between the groups. Microscopic avaliation observed statistic diference about fibrosis between group 1 and 3 (p0,05), but no diferences when analysed necrosis or inflamation. Conclusions: Viability of the spleen lower pole after subtotal splenectomy is not modified when its fixed to the stomach or when the posterior peritoneal Gastrosplenic Ligament is resected
Alvino Jorge Guerra - One of the best experts on this subject based on the ideXlab platform.
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Subtotal splenectomy preserving the lower pole in rats: technical, morphological and functional aspects
Acta cirurgica brasileira, 2006Co-Authors: Danilo Nagib Salomão Paulo, Isabel Cristina Andreatta Lemos Paulo, Mitre Kalil, Paulo Roberto Merçon De Vargas, Alcino Lázaro Da Silva, João Florêncio De Abreu Baptista, Alvino Jorge GuerraAbstract:PURPOSE: To assess the possibility of preserving the lower pole of the spleen, supplied by the inferior lobar vessels and segmental vessels, or by vessels of the Gastrosplenic Ligament, in subtotal splenectomy; to study the viability and function of the lower pole of the spleen. METHODS: Thirty-six male Wistar rats were used in this study. Said animals weighed 273-390 g ( 355.2 ± 30.5 g ), and were randomly distributed into three groups. Group 1 comprised ten animals which were submitted to exploratory laparotomy with spleen manipulation (sham operation). Group 2 comprised 16 animals which were submitted to total splenectomy. Group 3 comprised ten animals which were submitted to subtotal splenectomy, preserving the lower pole of the spleen. Blood was collected from all animals before and 90 days after surgery to measure the levels of cholesterol and triglycerides. The animals were sacrificed 90 days after surgery. Spleens and remaining spleens were removed for macroscopic and microscopic examination. RESULTS: Surgery was performed with no complications in all groups. Six animals died in group 2. Spleens of groups 1 and 2, and lower poles of group 3 were macroscopically viable. Apparent white pulp hyperplasia was observed in group 1. In group 3, slight inflammation and capsular fibrosis were observed at the incision site, as well as diffuse hemosiderosis in the red pulp. Average mass of remaining spleen was 35.84% ± 4.31%. No significant difference was observed between preoperative and late postoperative lipid levels in groups 1 and 3 (p > 0.05). Late postoperative lipid levels significantly increased in group 2. CONCLUSIONS: Preservation of the lower pole of the spleen (supplied by Gastrosplenic vessels or inferior lobar vessels and segmental vessels) was possible with subtotal splenectomy. The lower pole was macroscopically and microscopically viable in all cases. Subtotal splenectomy preserving the lower pole prevented changes in lipid levels, which were observed in rats submitted to total splenectomy. Plasma lipid levels in rats submitted to subtotal splenectomy were similar to those observed in sham operated rats.
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Subtotal splenectomy preserving the lower pole in rats: technical, morphological and functional aspects Esplenectomia subtotal com preservação do pólo inferior em ratos: aspectos técnicos, morfológicos e funcionais
Sociedade Brasileira para o Desenvolvimento da Pesquisa em Cirurgia, 2006Co-Authors: Danilo Nagib Salomão Paulo, Isabel Cristina Andreatta Lemos Paulo, Mitre Kalil, Alcino Lázaro Da Silva, João Florêncio De Abreu Baptista, Paulo Merçon Vargas, Alvino Jorge GuerraAbstract:PURPOSE: To assess the possibility of preserving the lower pole of the spleen, supplied by the inferior lobar vessels and segmental vessels, or by vessels of the Gastrosplenic Ligament, in subtotal splenectomy; to study the viability and function of the lower pole of the spleen. METHODS: Thirty-six male Wistar rats were used in this study. Said animals weighed 273-390 g ( 355.2 ± 30.5 g ), and were randomly distributed into three groups. Group 1 comprised ten animals which were submitted to exploratory laparotomy with spleen manipulation (sham operation). Group 2 comprised 16 animals which were submitted to total splenectomy. Group 3 comprised ten animals which were submitted to subtotal splenectomy, preserving the lower pole of the spleen. Blood was collected from all animals before and 90 days after surgery to measure the levels of cholesterol and triglycerides. The animals were sacrificed 90 days after surgery. Spleens and remaining spleens were removed for macroscopic and microscopic examination. RESULTS: Surgery was performed with no complications in all groups. Six animals died in group 2. Spleens of groups 1 and 2, and lower poles of group 3 were macroscopically viable. Apparent white pulp hyperplasia was observed in group 1. In group 3, slight inflammation and capsular fibrosis were observed at the incision site, as well as diffuse hemosiderosis in the red pulp. Average mass of remaining spleen was 35.84% ± 4.31%. No significant difference was observed between preoperative and late postoperative lipid levels in groups 1 and 3 (p > 0.05). Late postoperative lipid levels significantly increased in group 2. CONCLUSIONS: Preservation of the lower pole of the spleen (supplied by Gastrosplenic vessels or inferior lobar vessels and segmental vessels) was possible with subtotal splenectomy. The lower pole was macroscopically and microscopically viable in all cases. Subtotal splenectomy preserving the lower pole prevented changes in lipid levels, which were observed in rats submitted to total splenectomy. Plasma lipid levels in rats submitted to subtotal splenectomy were similar to those observed in sham operated rats.OBJETIVO: Avaliar a exequibilidade de preservação do pólo inferior suprido por vasos lobares inferiores e segmentares ou por vasos no Ligamento esplenogástrico, na esplenectomia subtotal, e estudar a viabilidade e a função desse pólo. MÉTODOS: Foram utilizados 36 ratos machos, Wistar, com peso entre 273 gramas e 390 gramas (M.A 355,2 ±30,5), distribuídos aleatoriamente em 3 grupos : grupo 1- 10 animais submetidos à laparotomia com manipulação do baço (operação simulada); grupo 2- 16 animais submetidos à esplenectomia total ; grupo 3- 10 animais submetidos à esplenectomia subtotal com preservação do pólo inferior. Em todos os animais foi colhido sangue no pré-operatório e no 90º P.O para dosagem do colesterol e frações e triglicérides. Os animais foram mortos após 90 dias e o baço e o remanescente esplênico foram retirados para estudo macro e microscópico. RESULTADOS: As operações nos três grupos foram realizadas sem dificuldades. Houve 6 óbitos no grupo da esplenectomia total. Os baços dos grupos 1 e 2 e os pólos inferiores do grupo 3 estavam macroscopicamente viáveis. Houve uma aparente hiperplasia da polpa branca no grupo simulação O pólo inferior apresentou áreas discretas de inflamação e fibrose capsular na área da incisão e hemossiderose difusa na polpa vermelha. O percentual médio de massa remanescente do pólo inferior foi 35,84% ± 4,31%. Não houve alterações significantes nos níveis de colesterol e frações e triglicérides no pós-operatório tardio em relação ao pré-operatório (P>0,05) nos grupos 1 e 3. No grupo 2 houve aumento significante do colesterol e frações e triglicérides no pós-operatório tardio. CONCLUSÕES: A preservação do pólo inferior suprido por vasos lobares inferiores e segmentares ou vasos no Ligamento esplenogástrico foi exeqüível na esplenectomia subtotal. Esse pólo manteve-se macro e microscopicamente viável em todos os casos. A esplenectomia subtotal com preservação do pólo inferior previne contra as alterações dos níveis de lípides plasmáticos observadas em ratos submetidos à esplenectomia total, e permite a manutenção dos níveis de lípides semelhantes aos do grupo simulação
Nicholas Gourtsoyiannis - One of the best experts on this subject based on the ideXlab platform.
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usefulness of the non distension of the stomach in the evaluation of perigastric invasion in advanced gastric cancer by ct
European Journal of Radiology, 1998Co-Authors: Konstantinos Gossios, Epameinondas V Tsianos, Panos Prassopoulos, Olympia Papakonstantinou, Evangelos C Tsimoyiannis, Nicholas GourtsoyiannisAbstract:The purpose of this study was to evaluate by CT the usefulness of the non-distension of the stomach in determining invasion of the gastric cancer into perigastric space and adjacent organs. Forty-eight patients with pathologically proved gastric cancer were studied by conventional CT. Patients were examined using two techniques: (a) non-distension of the stomach in the supine position and 34 patients additionally in prone position; and (b) distension of the stomach with water or air in the supine and/or prone position. CT findings by both techniques were separately analysed preoperatively and compared to surgical findings. Invasion of perigastric fat was better demonstrated by the non-distension technique in 15 of the 36 patients with pathologically proven fat infiltration. Non-distension technique was more accurate than distension in detecting: (a) involvement of gastric Ligaments (80 versus 67% for gastrohepatic, 85 versus 73% for gastrocolic and 80% by both techniques for Gastrosplenic Ligament); (b) perigastric lymphadenopathy (86% by both techniques for lymph nodes sited at the gastrohepatic Ligament, 85 versus 75% for gastrocolic and 85 versus 80% for Gastrosplenic Ligament lymph nodes, respectively); and (c) pancreatic invasion (86 versus 80%). The prone position with non-distended stomach was particularly helpful in excluding pancreatic invasion in five patients with carcinoma of the gastric body. The distension technique was more accurate in demonstrating perigastric extension in gastroesophageal junction tumors in two patients. In conclusion, additional CT of the non-distended stomach with the patient in prone position can provide further evidence about infiltration of the perigastric fat, Ligaments, lymph nodes and pancreas, in patients with gastric carcinoma, with the exception of gastroesophageal junction tumors.
