Gastrectomy for stomach cancer

Overview

Gastrectomy is surgery to remove some or all of the stomach. It is an important part of treatment for some people with stomach cancer. It may be done to remove a stomach tumor and nearby tissue. In some people with an inherited cancer risk, a healthcare team also may use this surgery to lower stomach cancer risk. The amount of stomach removed can range from a small piece to the entire stomach.

You may hear terms such as total, partial, subtotal, distal or proximal gastrectomy. These terms describe how much of the stomach is removed or which part is removed.

Surgeons may do gastrectomy with open, laparoscopic or robotic surgery. Open surgery uses one larger cut. Laparoscopic surgery and robotic surgery use several smaller cuts.

Other operations involving the stomach include sleeve gastrectomy, gastric bypass surgery and biliopancreatic diversion with duodenal switch. These operations are typically done to treat obesity and related health conditions. These procedures have different goals, such as improving metabolic health, compared with gastrectomy that is done to prevent or treat cancer or stomach lesions, such as ulcers or noncancerous tumors.

Types

The type of gastrectomy used for stomach cancer depends mainly on where the cancer is located and how much of the stomach needs to be removed.

• Total gastrectomy. In this surgery, the surgeon removes the entire stomach. Then the surgeon connects the esophagus to the small intestine so food can continue through the digestive tract.
• Partial or subtotal gastrectomy. The surgeon removes part of the stomach and part of it stays. Partial gastrectomy is a broad term. Subtotal gastrectomy usually means that the surgeon removes most, but not all, of the stomach.
• Distal gastrectomy. In this type of gastrectomy, the surgeon removes the lower part of the stomach, including the pylorus. The pylorus is the opening that controls the movement of food from the stomach into the small intestine. The upper part of the stomach stays.
• Antrectomy. The antrum is the lower part of the stomach. In an antrectomy, the surgeon removes the antrum. This surgery is a type of distal gastrectomy.
• Proximal gastrectomy. The surgeon removes the upper part of the stomach, including the area where the esophagus joins the stomach. The lower part of the stomach and the pylorus stay.
• Pylorus-preserving gastrectomy. The surgeon removes part of the middle of the stomach, while the pylorus and parts of the upper and lower stomach stay. The care team may use this procedure for treatment of selected early cancers in the middle of the stomach.
• Completion gastrectomy. The surgeon removes the rest of the stomach after removing part of the stomach earlier. The surgeon may need to do this if stomach cancer later develops in the part of the stomach that stays.

Other types include:

• Wedge gastrectomy or local resection. In this surgery, a surgeon removes a small part of the stomach instead of a full section around the stomach. The care team may use this approach for selected gastrointestinal stromal tumors (GISTs) when most of the stomach can stay.
• Segmental gastrectomy. A surgeon removes a section of the stomach all the way around. The upper opening of the stomach and the pylorus stay. Studies are researching this operation to find out if it can be used for gastric adenocarcinoma.
• Endoscopic submucosal dissection. In this procedure, a surgeon passes a tube called an endoscope through the mouth to the stomach. A surgeon passes tools through the endoscope to remove small early cancers from the stomach lining and tissue just beneath it.

A gastrectomy cannot be reversed. The part of the stomach that is removed cannot be put back.

Why it's done

Gastrectomy is used to remove stomach cancer that surgery can treat. The type of surgery depends mainly on where the tumor is found along the stomach wall and how much of the stomach needs to be removed.

When possible, the surgeon removes the cancer and enough tissue around it while preserving as much of the stomach as is appropriate. The surgeon usually removes nearby lymph nodes as well. Removing lymph nodes helps treat the cancer. And the lymph nodes can provide information about whether the cancer has spread.

The care team also may use gastrectomy to prevent stomach cancer in some people with a harmful change in the CDH1 gene. The CDH1 gene provides instructions for making a protein called E-cadherin. E-cadherin helps cells stick to one another and helps keep the structure of tissues. A harmful change in CDH1 can raise the risk of diffuse gastric cancer. For some people at high risk, the care team may recommend removing the stomach before cancer is found.

Risks

Gastrectomy is major surgery. Short-term risks can include:

• Bleeding.
• Wound infection.
• Blood clots.
• Breathing issues.
• Complications from anesthesia.
• Injury to nearby organs.
• A blockage in the digestive tract.
• A leak where parts of the digestive tract were joined. A leak can cause an infection in the abdomen.

Long-term effects depend partly on how much of the stomach is removed and how the digestive tract is reconnected. You may have nausea, vomiting, diarrhea or unintended weight loss. You also may feel full after eating a small amount. Heartburn, also called reflux, can occur after some types of gastrectomy.

Gastrectomy can make it harder to get enough calories, vitamins and minerals. It may be hard to get enough nutrients after a total gastrectomy. You may need vitamin B-12 or iron supplements and regular blood tests.

Dumping syndrome can happen when surgery causes food to move into the small intestine too quickly. Symptoms may include stomach pain, bloating, nausea, diarrhea, sweating, dizziness or a fast heartbeat. Some people later develop low blood sugar, which can cause hunger, weakness, sweating, shaking or confusion. Treatment usually starts with changes to what and how you eat.

Your care team takes steps to lower the risk of complications. Before surgery, the team checks your overall health and nutrition. After surgery, the team watches for complications and helps you begin moving as soon as it's safe. During follow-up, your healthcare team may check your weight and use blood tests to check vitamin and mineral levels.

How you prepare

Before gastrectomy for stomach cancer, your cancer care team decides whether surgery is the right treatment for you. The team also plans how much of the stomach to remove.

Tests may include CT scans, upper endoscopy and endoscopic ultrasound. You also may have staging laparoscopy. During this procedure, the surgeon makes small cuts in the abdomen and uses a thin tube with a camera to look for signs that the cancer has spread outside the stomach. This can help the care team decide whether surgery to remove the cancer is likely to be helpful.

Depending on the cancer stage, you may receive chemotherapy before and after surgery. You might have immunotherapy depending on the cancer's lab tests.

Nutrition is an important part of preparing for stomach cancer surgery. Your healthcare team may check your nutrition, strength and other health conditions. This is especially important if the cancer or trouble eating has caused weight or muscle loss. If you are not getting enough nutrition, your care team may recommend extra nutrition before surgery.

Your care team also gives you instructions about eating, drinking and medicines before surgery.

What you can expect

Before the procedure

Gastrectomy is done in a hospital under general anesthesia. This means you are in a sleep-like state and do not feel pain during surgery.

Before surgery, your healthcare team confirms the planned procedure and reviews your health and medicines. A team member places an IV in a vein and uses it to give fluids and medicines.

During the procedure

A surgeon may do gastrectomy with open, laparoscopic or robotic surgery. Open surgery uses one larger cut in the abdomen. Laparoscopic surgery and robotic surgery use several smaller cuts. With robotic surgery, the surgeon controls the robotic instruments.

The surgeon removes the planned part of the stomach. If the surgeon leaves part of the stomach, it is connected to the digestive tract as needed. After a total gastrectomy, which removes the entire stomach, the esophagus is connected to the small intestine.

During surgery for stomach cancer, the surgeon typically removes nearby lymph nodes as well. The goal is to remove the cancer with an area of tissue around it that does not contain cancer cells. A lab checks the edges, called margins, of the removed tissue for cancer cells. An edge without cancer cells is called a negative margin.

How long the operation takes depends on the type of gastrectomy and how the surgery is done.

After the procedure

After surgery, you go to a recovery area. Your care team checks your breathing, manages pain and watches for complications.

You start drinking and eating when it is safe. Your care team slowly adds food as you recover. When you can start drinking and eating depends on the type of gastrectomy and how your recovery is going.

Your hospital stay also depends on the type of surgery and your recovery.

Eating likely will change after part or all of your stomach is removed. You may find it easier to manage smaller meals more often. During follow-up, your care team may check your weight and levels of vitamins and minerals.

Results

After gastrectomy for stomach cancer, the removed stomach tissue and lymph nodes are examined in a lab.

A pathology report gives the results of lab tests on the removed tissue and lymph nodes. It shows whether cancer cells are in the lymph nodes or at the edges of the removed tissue. These results help the care team decide the stage of the cancer after the cancer is removed and whether you may need more treatment.

Stomach cancer can sometimes come back after surgery. The chance that it will come back, called recur, depends on the cancer stage, whether lymph nodes contain cancer and whether surgery removed all the cancer.

There is no single estimate for how long someone will live after gastrectomy for stomach cancer. Outlook depends on the cancer stage, your overall health and any other treatments you may need.

Diet and nutrition

Eating typically changes after gastrectomy. Having smaller meals more often may be easier than eating three larger meals. A dietitian can help you get enough calories and protein and help limit unintended weight loss. Your nutrition needs depend partly on how much of your stomach stays.

After a total gastrectomy, it can be hard to get enough nutrients. Long-term care often includes vitamin B-12 replacement and blood tests to check iron and other vitamins and minerals. Nutrition issues also can occur after partial gastrectomy.

If you develop dumping syndrome, changes in what and how you eat usually are the first treatment. These changes may include eating smaller amounts, drinking fluids between meals, and limiting foods and drinks high in sugar.

You may need nutrition supplements after stomach cancer surgery. Studies suggest that taking these supplements after leaving the hospital may help reduce unintended weight loss.