Surgery for stomach cancer

Surgery is part of the treatment for many different stages of stomach cancer if it can be done. If a patient has a stage 0, I, II, or III cancer and is healthy enough, surgery (often along with other treatments) offers the only realistic chance for cure at this time.

Surgery may be done to remove the cancer and part or all of the stomach and some nearby lymph nodes, depending on the type and stage of stomach cancer. The surgeon will try to leave behind as much normal stomach as possible. Sometimes other organs will need to be removed as well.

Even when the cancer is too widespread to be removed completely, patients may be helped by surgery because it may help prevent bleeding from the tumor or prevent the stomach from being blocked by tumor growth. This type of surgery is called palliative surgery, meaning that it relieves or prevents symptoms but it is not expected to cure the cancer.

The type of operation usually depends on what part of the stomach the cancer is in and how much cancer is in the surrounding tissue. Different kinds of surgery can be used to treat stomach cancer:

Endoscopic mucosal resection

This procedure is done only for some very early-stage cancers, where the chance of spread to the lymph nodes is very low.

The operation does not require an 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 a small wedge of normal stomach wall around it.

This operation is not done as much in the United States as it is in Japan and some other countries, where stomach cancer is often detected early during screening. If you are going to have this surgery, it should be at a center that has experience with this technique.

Subtotal (partial) gastrectomy

This operation is often recommended if the cancer is only in the lower part of the stomach. It is also sometimes used for cancers that are only in the upper part of the stomach.

Only part of the stomach is removed, sometimes along with part of the esophagus or the first part of the small intestine (the duodenum). 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, and possibly the spleen and parts of other nearby organs.

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 throughout 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 omentum, and may remove the spleen and parts of the esophagus, intestines, pancreas, or other nearby organs. 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 must eat more often.

Most subtotal and total gastrectomies are done through a large incision (cut) in the skin of the abdomen. Some centers are now studying the use of laparoscopic surgery for these operations, in which the surgeon operates through several smaller cuts in the abdomen (see “What’s new in stomach cancer research and treatment?”).

Placement of a feeding tube

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

Lymph node removal

In either a subtotal or total gastrectomy, the nearby lymph nodes are removed.

This is 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 with a gastrectomy, nearby lymph nodes be removed (called a D1 lymphadenectomy) with the goal of removing at least 15 nodes. Surgeons in Japan have had very high success rates by doing a more extensive removal of the 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 Japanese surgeons. It is not clear if this is because Japanese surgeons are more experienced (stomach cancer is much more common in their country), because Japanese 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 all the lymph nodes successfully. Ask your surgeon about his or her 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 unresectable stomach cancer, surgery can often still be used to help control the cancer or to help prevent or relieve symptoms or complications.

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 blockage in the stomach, even if it does not cure the cancer. Because the goal of this surgery is not to cure the cancer, nearby lymph nodes and parts of other organs usually do not need to be removed.

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 (called the jejunum) to the upper part of the stomach, which allows food to leave the stomach through the new connection.

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) can be used to guide a laser beam to vaporize parts of the tumor. This can be done to stop bleeding or help relieve a blockage without surgery.

Stent placement: Another 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) in 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.

Feeding tube placement: Some people with stomach cancer are not 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 distal part of the stomach (known as a gastrostomy tube or G tube) or into the small intestine (known as a jejunostomy tube or J tube). Liquid nutrition can then be put directly into the tube.

Possible complications and side effects of surgery

Surgery for stomach cancer is difficult 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 or esophagus and small intestine may leak.

Surgical techniques have improved in recent years, so only about 1% to 2% of people die from surgery for stomach cancer. This number is higher when the operation is more extensive, such as when all the lymph nodes 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 sewn together during the operation.

You may develop side effects after you recover from surgery. These can include nausea, heartburn, abdominal 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 too quickly after eating. The side effects often get better over time, but in some people they can last for a long time. Your doctor might prescribe medicines to help with this.

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.

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

Before your surgery, ask your surgeon how much of the stomach he or she intends to remove. Some surgeons try to leave behind as much of the stomach as they can to allow patients to eat more normally afterward. The tradeoff is that the cancer might be more likely to come back. The extent of the surgery should be discussed with your doctor before it is done.

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. To learn more about surgery for cancer, see our document Understanding Cancer Surgery: A Guide for Patients and Families.

Chemotherapy for stomach cancer

Chemotherapy (chemo) uses anti-cancer drugs that are injected into a vein or given by mouth as pills. These drugs enter the bloodstream and reach all areas of the body, making this treatment useful for cancer that has spread to organs beyond where it started.

Chemo can be used in different ways to help treat stomach cancer:

• Chemo can be given before surgery for stomach cancer. This, known as neoadjuvant treatment, can shrink the tumor and possibly make surgery easier. It may also help keep the cancer from coming back and help patients live longer. For some stages of stomach cancer, neoadjuvant chemo is one of the standard treatment options. Often, chemo is then given again after surgery.
• Chemo may be given after surgery to remove the cancer. This is called adjuvant treatment. The goal of adjuvant chemo is to kill any cancer cells that may have been left behind but are too small to see. This can help keep the cancer from coming back. Often, for stomach cancer, chemo is given with radiation therapy after surgery. This combination is called chemoradiation. This may be especially helpful for cancers that could not be removed completely by surgery.
• Chemo may be given as the primary (main) treatment for stomach cancer that has spread (metastasized) to distant organs. It may help shrink the cancer or slow its growth, which can relieve symptoms for some patients and help them live longer.

Doctors give chemo in cycles, with each period of treatment followed by a rest period to allow the body time to recover. Each cycle typically lasts for a few weeks.

A number of chemo drugs can be used to treat stomach cancer, including:

• 5-FU (fluorouracil), often given along with leucovorin (folinic acid)
• Capecitabine (Xeloda^®)
• Carboplatin
• Cisplatin
• Docetaxel (Taxotere^®)
• Epirubicin (Ellence^®)
• Irinotecan (Camptosar^®)
• Oxaliplatin (Eloxatin^®)
• Paclitaxel (Taxol^®)

Depending on the situation (including the stage of the cancer, the person’s overall health, and whether chemo is combined with radiation therapy), these drugs may be used alone or combined with other chemotherapy or targeted drugs.

Some common drug combinations used when surgery is planned include:

• ECF (epirubicin, cisplatin, and 5-FU),which may be given before and after surgery
• Docetaxel or paclitaxel plus either 5-FU or capecitabine, combined with radiation as treatment before surgery
• Cisplatin plus either 5-FU or capecitabine, combined with radiation as treatment before surgery
• Paclitaxel and carboplatin, combined with radiation as treatment before surgery

When chemo is given with radiation after surgery, a single drug such as 5-FU or capecitabine may be used.

To treat advanced stomach cancer, ECF may also be used, but other combinations may also be helpful. Some of these include:

• DCF (docetaxel, cisplatin and 5-FU)
• Irinotecan plus cisplatin
• Irinotecan plus 5-FU or capecitabine
• Oxaliplatin plus 5-FU or capecitabine

Many doctors prefer to use combinations of 2 chemo drugs to treat advanced stomach cancer. Three-drug combinations can have more side effects, so they are usually reserved for people who are in very good health and who can be followed closely by their doctor.

Side effects of chemotherapy

Chemo drugs attack cells that are dividing quickly, which is why they work against cancer cells. But other cells in the body, such as those in the bone marrow (where new blood cells are made), the lining of the mouth and intestines, and the hair follicles, also divide quickly. These cells can also be affected by chemo, which can lead to side effects. The type of side effect depends on the type of drugs, the amount taken, and the length of treatment. Short-term side effects common to most chemotherapy drugs can include:

• Nausea and vomiting
• Loss of appetite
• Hair loss
• Diarrhea
• Mouth sores
• Increased chance of infection (from a shortage of white blood cells)
• Bleeding or bruising after minor cuts or injuries (from a shortage of platelets)
• Fatigue and shortness of breath (from a shortage of red blood cells)

These side effects are usually short-term and go away once treatment is finished. For example, hair will usually grow back after treatment ends. Be sure to tell your cancer care team about any side effects you have because there are often ways to lessen them. For example, you can be given drugs to prevent or reduce nausea and vomiting.

Some chemotherapy drugs have specific side effects. You should be given specific information about each drug you are receiving and you should review it before you start treatment.

Neuropathy: Cisplatin, oxaliplatin, docetaxel, and paclitaxel can damage nerves outside the brain and spinal cord. This can sometimes lead to symptoms (mainly in the hands and feet) such as pain, burning or tingling sensations, sensitivity to cold or heat, or weakness. In most cases this goes away once treatment is stopped, but it may be long-lasting in some patients. Oxaliplatin can also affect nerves in the throat, causing throat pain that is worse when trying to eat or drink cold liquids or foods. This pain can lead to trouble swallowing or even breathing, and can last a few days after treatment.

Heart damage: Doxorubicin, epirubicin, and some other drugs may cause permanent heart damage if used for a long time or in high doses. For this reason, doctors carefully control the doses and use heart tests such as echocardiograms or MUGA scans to monitor heart function. Treatment with these drugs is stopped at the first sign of heart damage.

Low blood cell counts: This is a very common side effect of chemo.

Having a low white blood cell count can increase your risk of serious infection. If your white blood cell counts are very low during treatment, you can reduce your risk of infection by avoiding exposure to germs. During this time, your doctor may suggest that you:

• Wash your hands often.
• Avoid fresh, uncooked fruits and vegetables and other foods that might carry germs.
• Avoid fresh flowers and plants because they may carry mold.
• Make sure other people wash their hands before they come in contact with you.
• Avoid large crowds and people who are sick (wearing a surgical mask offers some protection in these situations).

You might be given drugs known as growth factors, such as G-CSF (Neupogen^®) and GM-CSF (Leukine^®), to increase your white blood cell count and thus reduce the chance of infection while you are on chemo. You might also be given antibiotics before you have signs of infection or at the earliest sign that an infection may be developing.

If your platelet counts are low, you might be given drugs or platelet transfusions to help protect against bleeding. Likewise, shortness of breath and extreme fatigue caused by low red blood cell counts may be treated with drugs or with red blood cell transfusions.

To learn more about chemotherapy, you can read our document Understanding Chemotherapy: A Guide for Patients and Families online, or call us for a free copy.