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Surgery for Cancer of the Stomach

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Stomach cancer is a challenging disease to treat, but more-targeted procedures – as part of individualized treatment plans – are improving care for this disease. Surgery continues to be the mainstay of treatment. In one form or another, it is the standard type of treatment for most stages of stomach cancer. Surgery is the only curative option for patients whose cancer is found early enough to be fully treated.

Also called gastric cancer, stomach cancer may be difficult to stage fully prior to surgical intervention. Although imaging studies and laparoscopy can provide much of the diagnosis, the findings from surgery help to confirm the degree of invasiveness of the cancer. The surgeon will be able to determine whether the cancer has invaded the stomach wall, and will remove nearby lymph nodes and sometimes tissue from other immediate areas of the abdomen for pathology analysis. Lymph nodes may contain cancerous cells that have disseminated from the primary tumor. Taking them out reduces the risk that the cancer will return in the future. Results of these steps will help to determine whether the patient should undergo chemotherapy or radiation therapy after surgery.

Removal of part or all of the stomach (gastrectomy) is the primary strategy in surgery for stomach cancer. The goal of such surgery is to remove the cancerous tissue but reconstruct the gastrointestinal tract to leave patients with a functioning digestive system so that they can continue to eat food orally. Gastrectomy is also used for other types of stomach conditions, such as chronic ulceration.

The earlier the cancer is diagnosed the better the chance that treatment will be curative. For very early stage cancers, the gastroenterologist may be able to remove the cancerous lesions nonsurgically using an endoscope, a slender, lighted tube introduced through the throat. But stomach cancer in its early stages produces few symptoms, and so most gastric cancers are more advanced when diagnosed.

A gastrectomy in any form is a major operation, involving a hospital stay of a week or more and many more weeks of recovery. Patients must be fit enough to be candidates for this surgery. Diarrhea for some weeks or months after surgery is common.

Subtotal or partial gastrectomy

For cancer in the lower portion of the stomach, surgeons can often remove just this diseased part of the organ, and then reattach the upper part of the stomach to a new location along the small intestine. The patient is left with a smaller stomach but with the sphincter-muscle containing connection of the esophagus and stomach intact. The surgeon also removes nearby lymph nodes and some of the tissue around the stomach. This spleen may be removed, as may a section of the small intestine. The operation is called a distal gastrectomy.

Sometimes, if the cancer is isolated in the upper portion of the stomach, surgeons can remove just this diseased part of the organ, reattaching the esophagus to the remaining lower portion of the stomach, and leaving the attachment of stomach to small intestine intact. . The spleen may be removed, as may be a small portion of the esophagus. This is called a proximal gastrectomy.

Performing these operations in which only a part of the stomach is removed results in a better nutritional outcome for the patient, compared to total removal of the stomach.

Total gastrectomy

When the cancer is more extensive, and not clearly isolated to the upper or lower half of the stomach, the surgeon will remove the entire stomach and a portion of the esophagus and small intestine. The surgeon will reconnect the esophagus directly to a new location on the small intestine. The surgeon also removes nearby lymph nodes and some of the tissue around the stomach. The spleen may be removed.

After this operation, the patient has essentially no stomach capacity and so has a feeling of fullness after eating just a modest amount of food. He or she must eat much smaller amounts of food much more frequently. After total gastrectomy, the patient will have to have injections of vitamin B12 for the rest of his or her life.

Esophagogastrectomy

In this procedure, the surgeon has determined that the stomach cancer is close enough to bottom of the esophagus, or there is enough evidence of cancerous involvement of the esophagus, that the lower portion of the esophagus must also be removed, along with all of the other steps involved in a proximal gastrectomy. The upper part of the stomach is removed, but the lower portion of the stomach is retained and reattached to the remaining esophagus. In some cases involving more extensive esophageal cancer, a section of the colon is used to connect the remaining esophagus to the stomach.

Intraperitoneal (IP) chemotherapy

When colorectal cancers have invaded the peritoneal cavity – meaning the space outside, between, and around the surface of the lower abdominal organs (intestines, liver, and pancreas), as well as the lining and connective tissue (peritoneum) in that part of abdomen – the knowledgeable cancer team can treat the disease by infusing chemotherapeutic drugs into this area. The surgeon will place a catheter into the abdominal area, allowing the cancer-killing drugs to be introduced for varying periods of time into the peritoneal space and then withdrawn. This increases the concentration of drugs acting on the cancer tissue and decreases the amount that reaches the rest of body, compared to the conventional intravenous route of administration. The strategy enhances the chemotherapeutic effects of the drugs and decreases their systemic side effects. Typically, patients receive IP chemotherapy after surgery that removes as much of the visible cancer tissue as possible.

Palliative surgery

Sometimes stomach cancer is too advanced or too widespread to be completely removed, and curative surgery is not possible. However, surgical treatment can still be beneficial in addressing and reducing symptoms.

Sometimes the tumor can be significant enough to block the stomach. The cancer team may place a stent to open passage into or through the stomach, or may use laser endoscopy or electrocautery to remove tumor.