Stomach cancer surgery
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Parminder Dhingra, M.D. [2]
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Overview
Surgery is the mainstay of treatment for stomach cancer.
Surgery
Surgery is a common treatment of all stages of gastric cancer. The following types of surgery may be used:
- Subtotal gastrectomy: Removal of the part of the stomach that contains cancer, nearby lymph nodes, and parts of other tissues and organs near the tumor. The spleen may be removed. The spleen is an organ in the upper abdomen that filters the blood and removes old blood cells.
- Total gastrectomy: Removal of the entire stomach, nearby lymph nodes, and parts of the esophagus, small intestine, and other tissues near the tumor. The spleen may be removed. The esophagus is connected to the small intestine so the patient can continue to eat and swallow.
If the tumor is blocking the stomach but cancer cannot be completely removed by standard surgery, the following procedures may be used:
- Endoluminal stent placement: A procedure to insert a stent (a thin, expandable tube) in order to keep a passage (such as arteries or the esophagus) open. For tumors blocking the passage into or out of the stomach, surgery may be done to place a stent from the esophagus to the stomach or from the stomach to the small intestine to allow the patient to eat normally.
- Endoluminal laser therapy: A procedure in which an endoscope (a thin, lighted tube) with a laser attached is inserted into the body. A laser is an intense beam of light that can be used as a knife.
- Gastrojejunostomy: Surgery to remove the part of the stomach with cancer that is blocking the opening into the small intestine. The stomach is connected to the jejunum (a part of the small intestine) to allow food and medicine to pass from the stomach into the small intestine.
Early gastric cancer
Early gastric cancer is an invasive gastric cancer that invades no more than the submucosa whatever the lymph node metastasis condition (T1 and any N)
Endoscopic resection is suggested for:
- Patients without suspected lymph node involvement
- Tumor size <20 mm in diameter
- Differentiated intestinal histology
In most trials, there are no differences in outcome between the surgical and the endoscopic treatment. [1,2]
Standard criteria for endoscopic resection:
1) Confined to the mucosa
2) Smaller than 2 cm for superficially elevated type lesions
3) Smaller than 1 cm for the flat and depressed type lesions
4) Without ulcer or ulcer scar
5) Without venous or lymphatic involvement [3-7]
Expansion of the criteria to involve more tumors eligible for endoscopic resection was suggested by japanese centers and these criteria include [8-11]. [8,12,13]
- Differentiated type without ulceration, and mucosal tumors of any size
- Differentiated type, with ulceration, and mucosal tumors less than 30 mm
- Undifferentiated type, without ulceration, and mucosal tumors 20 mm in size or smaller
In a Japanese report of 131 patients with differentiated mucosal early gastric cancer less than 2 cm, the 5- and 10-year overall survival rates were 84 and 64 percent, respectively. The disease-specific survival rates at both 5- and 10-year follow-up were 99 percent [14].
Methods of endoscopic resection
- Endoscopic mucosal resection (EMR): The lesion, together with the surrounding mucosa, is lifted by submucosal injection of saline and removed using a high-frequency steel snare.
- Endoscopic submucosal dissection (ESD): The mucosa surrounding the lesion is circumferentially incised using a high-frequency electric knife. 37
- ESD is more likely to result in complete resection of early gastric cancer [36]
- ESD requires more procedure time and endoscopic skill
Side effects and complications:
Bleeding
- Bleeding was observed in 30 percent of cases. [119].
- A tumor size of more than 4 cm is a risk factor for acute bleeding and antithrombotic drug therapy is a risk factor for delayed bleeding.
- Bleeding treatment is injection therapy, electrocoagulation, ligation with a detectable snare, and endoscopic clipping.
Perforation
- Perforation rate for ESD is 4.5 percent, compared with 1.0 percent for EMR [89].
- Tumor location in the upper stomach and size more than 2 cm have been associated with an increased risk of perforation with ESD. [124].
- Treatment of a perforation is endoscopic clipping, open or laparoscopic surgery in case of failed clipping. [122,123].
Curative resection
Criteria need to be fulfilled to consider endoscopic resection curative:
- En bloc resection
- Tumor size < 2 cm
- Histologically of differentiated type
- Staging of tumor < T1a
- Negative horizontal margin
- Negative vertical margin
- No lymphovascular infiltration
Any resection that does not satisfy any of the above criteria is considered non-curative.
Managing noncurative resection
- There is no standard approach for managing these patients noncurative resection. Gastrectomy has been recommended especially for tumors associated with a higher risk for lymph node metastases.
- Gastrectomy with removal of perigastric lymph nodes is recommended for such patients [42].
- Seven percent of patients who had gastrectomy and lymph node dissection after noncurative endoscopic resection for early gastric cancer had lymph node metastasis after that. [40]
Positive margins management
- Patients with only positive lateral margins can be managed with further endoscopic therapy rather than surgery. Almost 90 percent of lateral psotitve margins were followed endoscopically with no recurrences.
- Patients with positive vertical margins, submucosal invasion, or lymphovascular invasion, are treated by surgery.[16]
Local recurrence after EMR/ESD
Local mucosal recurrence after EMR/ESD for tumors that had fulfilled the absolute indication could be considered to meet the criteria for expanded indication and may be treated by another ESD.
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