Surgery

When the cancer is confined to the stomach, surgery is the essential component to all curative treatments for gastric cancer. The goal of surgery for potentially curable stomach cancer is to remove all of the cancer while preserving as much of the patient's normal gastric function as possible. All stomach cancer surgery is complex and ideally should be performed by an experienced surgical oncologist working together with other members of a multidisciplinary team to achieve optimal outcomes.

The surgery usually consists of removing the affected portion of the stomach with adequate margins and the nearby lymph nodes, a procedure known as gastrectomy.  This can be either a partial or total removal of the stomach.  The specific operation performed is based on the location and pathologic type of stomach cancer.  There are a variety of options for reconnecting the intestinal tract to the stomach or esophagus to re-establish intestinal continuity and permit the ability to eat regular food. The reconstructive options depend on the type and extent of the operation needed to remove the tumor. For example, a total gastrectomy might be required for a more diffuse type of gastric cancer in order to ensure that the entire tumor has been removed.  In these situations, the small intestine is connected directly to the esophagus with or without some type of reservoir or pouch reconstruction.  In other situations, a portion of the native stomach can be preserved and the small intestine is connected directly to the residual stomach. Occasionally, a temporary feeding tube is inserted through the skin into the small intestine at the time of surgery to provide additional nutrition during the recovery period. Most patients spend about a week in the hospital and then recover at home for about 4-8 weeks before resuming regular activities or additional treatments.

Although surgery is an essential part of any curative approach to stomach cancer, surgery alone is often not enough.  Most patients with potentially curable gastric cancer will receive additional therapy to prevent the cancer from recurring or coming back.  These additional (also called adjuvant therapy) treatments for gastric cancer are sometimes given before or after surgery depending on the type and stage of gastric cancer involved. The rationale for combining these treatments with surgery is to treat any residual microscopic cancer cells that may exist before or after surgery.  In some situations, chemotherapy is given for a few months before surgery followed by a recovery period prior to the planned surgery.  Additional chemotherapy may follow.  In other situations, a combination of chemotherapy and radiation therapy may be given after the patient has adequately recovered (generally 4-8 weeks) from the operation. The amount and type of treatment depends on the extent of the cancer and the overall health of the patient.

For patients with metastatic gastric cancer that cannot be cured with an operation, surgery may still be recommended based on symptoms such as obstruction, bleeding or pain that cannot be controlled by other means.  These operations are done for palliative relief of symptoms and require experience, judgment, and realistic expectations of the palliative goals of treatment.

Removing a portion or all of the stomach has an impact on eating and nutrition but perhaps less so than most people would imagine.  Most patients initially experience a diminished appetite and a sensation of being full with relatively little food intake.  As a consequence, patients often start off eating smaller meals spread out over more time and have to "work" more at getting enough nutrition to maintain weight.  There may be some changes in the recommended diet depending on the type of surgery performed; however, many patients are able to gradually resume eating regular food with some modifications.  It frequently takes several months to settle into a new eating routine.  The human body and intestinal tract have an amazing capacity to adapt and compensate for the changes brought about by surgery and the other treatments employed for gastric cancer.

By Martin McCarter, MD
Professor of Surgery and Surgical Director of the Esophageal and Gastric Multidisciplinary Cancer Clinic
University of Colorado School of Medicine
Aurora, Colorado

(January 1, 2014)

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