Surgery for stomach cancer

Surgery is often used to treat stomach cancer. The type of surgery you have depends mainly on the size of the tumour and stage of the cancer. When planning surgery, your healthcare team will also consider other factors, such as:

• the type of stomach cancer
• your age
• how well your organs are working and your overall health
• your nutritional status (how well your body's nutritional needs are being met)

Surgery may be done for different reasons. You may have surgery to:

• completely remove the tumour and nearby lymph nodes
• remove as much of the tumour as possible before other treatments
• rebuild (reconstruct) the gastrointestinal (GI) tract after the stomach has been removed
• ease pain and other symptoms of advanced stomach cancer (called palliative surgery)

The following types of surgery are used to treat stomach cancer. You may also have other treatments before or after surgery.

Surgery for stomach cancer is done using a general anesthetic (a drug that puts you into a deep sleep so you don't feel pain).

An endoscopic resection (ER) is a specialized surgery used to treat small (smaller than 2 cm), early stage stomach cancer that has not spread beyond the inner lining of the stomach (called the mucosa) or the surrounding connective tissue layer (called the submucosa). The cancer is at a low risk of spreading to nearby lymph nodes.

Depending on how the tissue is removed, an ER can be called an endoscopic mucosal resection (EMR) or an endoscopic submucosal dissection (ESD). An EMR is the more common.

For an ER, an endoscope is passed through the mouth, down the throat and into the stomach. Surgical tools remove the tumour from the wall of the stomach. Fluid may be injected under the tumour to lift it away from the stomach wall so it can be removed more easily.

In Canada, very few stomach cancers are treated with an ER because stomach cancer is rarely found at such an early stage.

A limited surgical resection (also called a wedge resection) removes the section of the stomach wall that contains the tumour along with a margin of healthy tissue around the tumour. A limited surgical resection is sometimes used to treat small (smaller than 3 cm), early stage stomach cancer.

A limited surgical resection may be done by open surgery to the abdomen (called a laparotomy) or by laparoscopy.

A gastrectomy is the most common surgery used to treat stomach cancer. It removes all or part of the stomach. Sometimes other organs or areas are removed during a gastrectomy, such as the omentum. During the same surgery, lymph nodes around the stomach are also removed (called a lymph node dissection).

The surgeon usually makes a large cut (incision) in the abdomen to remove the stomach. In recent years, some surgeons are doing laparoscopic surgery. For this type of surgery, the surgeon makes several small cuts and then inserts an endoscope and special tools to remove the stomach.

The type of gastrectomy done depends on the stage and where the cancer is within the stomach.

A lymph node dissection is surgery to remove several lymph nodes from the body. It is done for stomach cancer during gastrectomy surgery.

A lymph node dissection is classified by the location of the lymph nodes that are removed. A D1 lymph node dissection removes the lymph nodes attached to the outer wall of the area of the stomach that contains the tumour. A D2 lymph node dissection removes D1 lymph nodes plus the lymph nodes around several large blood vessels near the stomach. A D2 lymph node dissection is a longer and more complicated surgery.

Find out more about a lymph node dissection.

Surgery may be used to relieve the symptoms of advanced stomach cancer including:

• bleeding
• pain
• the inability to eat
• an obstruction or a blockage (the tumour may block the passage of food into or through the stomach)
• a perforation (the tumour may grow through the wall of the stomach, creating a hole into the abdomen)

The type of palliative surgery will depend on your symptoms, the location of the stomach tumour and your overall health.

Surgery may be done to change the flow of food or fluids around a tumour that is blocking the stomach or esophagus. The part of the stomach that is above the blockage is cut and then reattached to the small intestine. This allows the food to move through the stomach and into the small intestine. Stomach bypass surgery is also called a gastrojejunostomy.

Stomach bypass surgery may be done if you cannot have a gastrectomy because of health problems or if removing the tumour would not improve your quality of life.

A bowel obstruction is when the small intestine or colon is partly or completely blocked. The blockage prevents food, fluids and gas from passing through the intestines normally. If you have a bowel obstruction, you may need surgery to remove or bypass the part of the intestine that is blocked.

A limited surgical resection (described above) may also be used for people with advanced stomach cancer. The goal is to remove as much of the tumour as possible to try to relieve a blockage or bleeding that is hard to stop.

A stent is a hollow metal or plastic tube. Stents may be used if a tumour is blocking the opening of the stomach near the esophagus. It will allow a person with advanced stomach cancer to swallow more easily. A stent may also be placed at the opening to the duodenum to allow food to pass from the stomach into the small intestine.

The doctor places the stent using an endoscope. The endoscope is passed through the mouth, down the esophagus and into the stomach.

If surgery or other treatments cannot relieve a blockage caused by a stomach tumour, a feeding tube may be placed through a surgical opening in the abdomen. A feeding tube may also be used for a short time after surgery for stomach cancer.

A feeding tube is used to give liquid nutrition to help maintain a healthy weight. The tube may also be used to give medicines. A feeding tube may be placed into the:

• stomach (called a gastrostomy tube, or G-tube)
• small intestine (called a jejunostomy tube, or J-tube)

Endoscopic tumour ablation uses laser surgery to destroy some of the stomach tumour. This technique may be used in people who can't have surgery. It may be done to stop bleeding or to relieve a tumour blockage in people with advanced stomach cancer. It may also help a person to eat more easily.

Side effects can happen with any type of treatment for stomach cancer, but everyone's experience is different. Some people have many side effects. Other people have only a few side effects.

If you develop side effects, they can happen any time during, immediately after or a few days or weeks after surgery. Sometimes late side effects develop months or years after surgery. Most side effects will go away on their own or can be treated, but some may last a long time or become permanent.

Side effects of surgery will depend mainly on the type of surgery and your overall health. Surgery for stomach cancer may cause these side effects:

• pain
• bleeding
• blood clots
• infection
• dumping syndrome
• damage to nearby organs, such as the small intestine or spleen
• leaking from where the stomach or esophagus and the small intestine were joined (called an anastomotic leak)
• lack of vitamin B12 (deficiency)

Tell your healthcare team if you have these side effects or others you think might be from surgery. The sooner you tell them of any problems, the sooner they can suggest ways to help you deal with them.

Find out more about surgery and side effects of surgery. To make the decisions that are right for you, ask your healthcare team questions about surgery.