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.
Surgical management of invasive gastric cancer
Surgical eradication of a gastric tumor with resection of adjacent lymph nodes represents the best chance for long-term survival.
Types of gastric surgery
Curative surgery
- Standard gastrectomy: It is the principal surgical procedure performed with curative intent. It involves resection of at least two-thirds of the stomach with a D2 lymph node dissection. In the standard gastrectomy, two-thirds of the stomach is resected.
- Non-standard gastrectomy: In non-standard gastrectomy, the extent of gastric resection and/or lymphadenectomy is altered according to tumor stages.
- Modified surgery: The extent of gastric resection and lymphadenectomy is reduced compared to standard surgery.
- Extended surgery
- Gastrectomy with combined resection of adjacent involved organs
- Gastrectomy with extended lymphadenectomy exceeding D2
Surgery for gastric cancer
- Total gastrectomy: Total resection of the stomach including the cardia and pylorus.
- Distal gastrectomy: Stomach resection including the pylorus. The cardia is preserved.
- Pylorus-preserving gastrectomy: Stomach resection preserving the upper third of the stomach and the pylorus along with a portion of the antrum.
- Proximal gastrectomy: Stomach resection including the cardia (esophagogastric junction). The pylorus is preserved.
- Segmental gastrectomy: Circumferential resection of the stomach preserving the cardia and pylorus.
- Local resection.
- Non-resectional surgery (bypass surgery, gastrostomy, jejunostomy).
Determination of gastric resection
- Resection margin A sufficient resection margin should be ensured when determining the resection line in gastrectomy with curative intent.
- Proximal margin of at least 3 cm is recommended for T2 or deeper tumors with an expansive growth pattern (types 1 and 2) and 5 cm for those with an infiltrative growth pattern (types 3 and 4).
- For tumors invading the esophagus, a 5-cm margin is not necessarily required,
but frozen section examination of the resection line is
desirable to ensure an R0 resection.
For T1 tumors, a gross resection margin of 2 cm should
be obtained. When the tumor border is unclear, preoperative
endoscopic marking by clips of the tumor border based
on biopsy results will be helpful for decision making
regarding the resection line.
Selection of gastrectomy The standard surgical procedure
for clinically node-positive (cN?) or T2-T4a tumors is either
total or distal gastrectomy. Distal gastrectomy is selected
when a satisfactory proximal resectionmargin (see above) can
be obtained. Pancreatic invasion by tumor requiring pancreaticosplenectomy
necessitates total gastrectomy regardless of
the tumor location. Total gastrectomy with splenectomy
should be considered for tumors that are located along the
greater curvature and harbor metastasis to no. 4sb lymph
nodes, even if the primary tumor could be removed by distal
gastrectomy. For adenocarcinoma located on the proximal
side of the esophagogastric junction, esophagectomy and
proximal gastrectomy with gastric tube reconstruction should
be considered, similarly to surgery for esophageal cancer.
For cT1cN0 tumors, the following types of gastric
resection can be considered according to tumor location.
– Pylorus-preserving gastrectomy (PPG): for tumors in
the middle portion of the stomach with the distal tumor
border at least 4 cm proximal to the pylorus.
– Proximal gastrectomy: for proximal tumors where more
than half of the distal stomach can be preserved.
– Segmental gastrectomy and local resection under
sentinel navigation are still regarded as investigational
treatments.
One of the most controversial areas in the surgical management of gastric cancer is the optimal extent of lymph node dissection. [46].
The draining lymph node basins for the stomach have been meticulously divided into 16 stations by Japanese surgeons
stations 1 to 6 are perigastric, and the remaining 10 are located adjacent to major vessels, behind the pancreas, and along the aorta [47].
D1 lymphadenectomy refers to a limited dissection of only the perigastric lymph nodes.
D1+ lymphadenectomy
A D1+ lymphadenectomy is
indicated for T1N0 tumors other than the above.
D2 lymphadenectomy is an extended lymph node dissection, entailing removal of nodes along the hepatic, left gastric, celiac, and splenic arteries, as well as those in the splenic hilum (stations 1 to 11).
D2 lymphadenectomy
A D2 lymphadenectomy is indicated
for potentially curable T2-T4 tumors as well as
T1N+ tumors.
D3 dissection is a superextended lymphadenectomy. The term has been used by some to describe a D2 lymphadenectomy plus the removal of nodes within the porta hepatis and periaortic regions (stations 1 to 16), while others use the term to denote a D2 lymphadenectomy plus periaortic nodal dissection (PAND) alone [48].
Most Western surgeons (and the American Joint Committee on Cancer [AJCC]/Union for International Cancer Control [UICC] tumor, node, metastasis [TNM] staging classification [23]) classify disease in these regions as distant metastases and do not routinely remove nodes in these areas during a potentially curative gastrectomy.
Indications for lymph node dissection
In principle, a D1 or a D1+ lymphadenectomy is indicated
for T1N0 tumors and D2 for N+ or T2-T4 tumors.
a D2 lymphadenectomy should be performed whenever nodal involvement is suspected.
D1 lymphadenectomy
A D1 lymphadenectomy is indicated
for T1a tumors that do not meet the criteria for EMR/
ESD and for cT1bN0 tumors that are histologically of
differentiated type and 1.5 cm or smaller in diameter.
Complete clearance of No. 10 nodes by splenectomy should be
considered for potentially curable T2-T4 tumors invading
the greater curvature of the upper stomach.
[4].
The role of No. 14v lymphadenectomy in distal gastric
cancer is controversial. Dissection of No. 14v had been
a part of D2 gastrectomy defined by the 13th edition of
the Japanese Classification of Gastric Carcinoma, but
was excluded from the previous version (version 3) of
the Japanese Gastric Cancer Treatment Guidelines and
remains that way in the current version. However, D2
(?No. 14v) may be beneficial for patients who are
suspected to harbor metastasis to the No. 6 nodes.
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| Differentiated,≤2cm | Differenitated,≤1.5cm | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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