Surgery for Stomach Cancer

Surgery is often part of the treatment for stomach cancer (gastric cancer), if it can be done. If the cancer hasn't spread to other parts of the body, surgery (often along with other treatments) offers the best chance to try to cure the cancer.

Surgery can be done for two main reasons:

• Surgery to remove the cancer: Surgery may be done to remove the cancer and part or all of the stomach, as well as some nearby lymph nodes and other structures, depending on the location and stage (extent) of the cancer. The surgeon will try to leave behind as much normal stomach as possible. Sometimes other organs will need to be removed as well.
• Palliative surgery: If the cancer is too widespread to be removed completely, surgery might still be done to help prevent bleeding from the tumor or prevent the stomach from being blocked by tumor growth. This type of surgery can prevent or relieve symptoms, but it is not expected to cure the cancer.

Surgery to remove the cancer

Different types of surgery can be used to try to remove stomach cancer. The type of operation used depends on what part of the stomach the cancer is in and how far it has grown into nearby areas.

Before your surgery, talk to your surgeon about how much of the stomach will need to be removed. Some surgeons try to leave behind as much of the stomach as they can, which might allow patients to eat more normally afterward. However, the main goal of surgery is to be sure all the cancer has been removed. The surgeon will try to achieve negative surgical margins, meaning that no cancer cells are seen at the edges of the removed part of the stomach, even when looking at it under a microscope.

Endoscopic resection

Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are procedures that can be used to treat some very early-stage cancers, when the tumor is not thought to have grown deeply into the stomach wall and the chance of spread outside the stomach is very low.

These procedures do not require a cut (incision) in the skin. Instead, the surgeon passes an endoscope (a long, flexible tube with a small video camera on the end) down the throat and into the stomach. Surgical tools can be passed through the endoscope to remove the tumor and some layers of the normal stomach wall below and around it. (ESD goes deeper into the stomach wall than EMR.)

These operations are not done as often in the United States as they are in some East Asian countries (like Japan) where stomach cancer is more common and more often found at an early stage due to screening. If you are going to have this kind of surgery, it should be done at a center that has experience with this technique.

Subtotal (partial) gastrectomy

In this operation, only part of the stomach is removed. This is often recommended if the cancer is only in the lower part of the stomach (in which case it is known as a distal gastrectomy). It might also be used for cancers that are only in the upper part of the stomach (in which case it is known as a proximal gastrectomy).

Part of the stomach is removed, sometimes along with part of the esophagus (in a proximal gastrectomy) or the first part of the small intestine (in a distal gastrectomy). The remaining section of stomach is then reattached. Some of the omentum (an apron-like layer of fatty tissue that covers the stomach and intestines) is removed as well, along with nearby lymph nodes. If the cancer has reached the spleen or parts of other nearby organs, these are removed as well.

Eating is much easier after surgery if only part of the stomach is removed instead of the entire stomach.

Total gastrectomy

This operation is done if the cancer has spread widely in the stomach. It is also often advised if the cancer is in the upper part of the stomach, near the esophagus.

The surgeon removes the entire stomach, nearby lymph nodes, and the omentum, and may remove the spleen and parts of the esophagus, intestines, pancreas, or other nearby organs if the cancer has reached them. The end of the esophagus is then attached to part of the small intestine. This allows food to move down the intestinal tract. But people who have had their stomach removed can only eat a small amount of food at a time. Because of this, they will need to eat more often.

Surgical approaches to subtotal or total gastrectomy

Most subtotal and total gastrectomies are done through a large incision (cut) in the skin of the abdomen (belly). This is sometimes referred to as an open surgical approach.

In some centers, these operations are done as a laparoscopic gastrectomy, in which long, thin surgical instruments (including one with a small video camera on the end) are inserted into the abdomen through several small cuts. Some surgeons do these operations using robotic-assisted laparoscopic surgery (sometimes just called robotic surgery). In this technique, the surgeon sits at a control panel and moves robotic arms that have laparoscopic instruments on the ends. (For more on this, see What’s New in Stomach Cancer Research?)

Although the laparoscopic approach (including robotic surgery) might result in a shorter hospital stay, less pain after the operation, and a shorter recovery time (because of the smaller incisions), many doctors feel that this technique needs to be studied further before it can be considered a standard treatment for stomach cancer.

No matter which approach is used, it’s important that your surgeon is skilled and experienced with the technique.

Lymph node removal

In either a subtotal or total gastrectomy, the nearby lymph nodes are removed. This is known as a lymph node dissection or lymphadenectomy, and it's a very important part of the operation. Many doctors feel that the success of the surgery is directly related to how many lymph nodes the surgeon removes.

In the United States, it is recommended that at least 16 lymph nodes be removed (called a D1 lymphadenectomy) when a gastrectomy is done. Surgeons in some East Asian countries (such as Japan and South Korea) have had very high success rates by removing even more lymph nodes near the cancer (called a D2 lymphadenectomy).

Surgeons in Europe and the United States have not been able to equal the results of the East Asian surgeons. It is not clear if this is because East Asian surgeons are more experienced (stomach cancer is much more common in these countries), because their patients tend to have earlier stage disease (because they screen for stomach cancer) and are healthier, or if other factors play a role.

In any event, it takes a skilled surgeon who is experienced in stomach cancer surgery to remove as many lymph nodes as possible. Ask your surgeon about their experience in operating on stomach cancer. Studies have shown that the results are better when both the surgeon and the hospital have had extensive experience in treating patients with stomach cancer.

Palliative surgery for unresectable cancer

For people with stomach cancer that can't be removed completely, surgery can often still be used to help control the cancer or to help prevent or relieve symptoms or complications.

Gastric bypass (gastrojejunostomy)

Tumors in the lower part of the stomach may eventually grow large enough to block food from leaving the stomach. For people healthy enough for surgery, one option to help prevent or treat this is to bypass the lower part of the stomach. This is done by attaching part of the small intestine (the jejunum) to the upper part of the stomach, which allows food to leave the stomach through the new connection.

Subtotal gastrectomy

For some people who are healthy enough for surgery, removing the part of the stomach with the tumor can help treat problems such as bleeding, pain, or the tumor blocking the passage of food through the stomach, even if the surgery does not cure the cancer. Because the goal is not to cure the cancer, nearby lymph nodes and parts of other organs usually do not need to be removed.

Feeding tube placement

Some people with stomach cancer aren’t able to eat or drink enough to get adequate nutrition. A minor operation can be done to place a feeding tube through the skin of the abdomen and into the lower part of the stomach (known as a gastrostomy tube or G tube) or into the small intestine (jejunostomy tube or J tube). Liquid nutrition can then be put directly into the tube.

Endoscopy procedures

In some situations, upper endoscopy procedures can be done to help prevent or relieve symptoms, without the need for more extensive surgery:

• Endoscopic tumor ablation: In some cases, such as in people who are not healthy enough for surgery, an endoscope (a long, flexible tube passed down the throat) with a laser on the end can be used to vaporize parts of the tumor. This can be done to stop bleeding or help relieve a blockage without surgery.
• Stent placement: Another non-surgical option to keep a tumor from blocking the opening at the beginning or end of the stomach is to use an endoscope to place a stent (a hollow metal tube) into the opening. This helps keep it open and allows food to pass through it. For tumors in the upper (proximal) stomach, the stent is placed where the esophagus and stomach meet. For tumors in the lower (distal) part of the stomach, the stent is placed at the junction of the stomach and the small intestine.

Possible complications and side effects of surgery

Surgery for stomach cancer is complex and can have complications. These can include bleeding from the surgery, blood clots, and damage to nearby organs during the operation. Rarely, the new connections made between the ends of the stomach, esophagus, and small intestine may leak.

Surgical techniques have improved in recent years, so only a very small percentage of people die from surgery for stomach cancer. The chance of this happening is higher when the operation is more extensive, such as when other organs are removed, but it is lower in the hands of highly skilled surgeons.

You will not be allowed to eat or drink anything for at least a few days after a total or subtotal gastrectomy. This is to give the digestive tract time to heal and to make sure there are no leaks in parts that have been connected together during the operation.

Side effects after surgery can include nausea, heartburn, abdominal (belly) pain, and diarrhea, particularly after eating. These side effects result from the fact that once part or all of the stomach is removed, food enters the intestines much more quickly after eating. These side effects might get better over time, but for some people they might not. Your doctor might prescribe medicines to help with them.

Changes in your diet will be needed after a partial or total gastrectomy. The biggest change is that you will need to eat smaller, more frequent meals. The amount of stomach removed will affect how much you need to change the way you eat.

Some people might have trouble taking in enough nutrition after surgery for stomach cancer. Further treatment like chemotherapy and radiation after surgery can make this problem worse. To help with this, a tube is sometimes placed into the intestine, either at the time of the surgery or afterward. The other end of this tube, called a jejunostomy tube or J tube, remains outside of the skin on the abdomen. Liquid nutrition can be put directly through this tube into the intestine to help prevent or treat malnutrition.

The stomach helps the body absorb some vitamins, so people who have had a subtotal or total gastrectomy might develop vitamin deficiencies. If certain parts of the stomach are removed, doctors routinely prescribe vitamin supplements, some of which can only be injected.

It cannot be stressed enough that you should make sure your surgeon is experienced in treating stomach cancer and able to perform the most up-to-date operations to reduce your risk of complications.