Surgical Procedures: Surgery and Staging for Gastric Cancer

Cancerous cells in the lining of the stomach are called gastric cancer. The stomach is a J-shaped organ that sits in the top part of the belly. It helps break down and digest food and processes nutrients. After food is partially digested in the stomach, it is then moved to the small intestine.

The stomach is very muscular and has many parts and layers to it. There are five main parts of the stomach: the cardia, fundus, body, antrum, and pylorus. The layers of the stomach include the serosa, subserosa, the muscularis propria, the submucosa, and the mucosa. Most gastric cancers begin in the mucosa, or the innermost layer of the stomach (the layer that comes into contact with food).

The most common type of gastric cancer is adenocarcinoma. Other less common types of gastric cancers include:

• Lymphoma.
• Gastrointestinal stromal tumor (GIST).
• Carcinoid tumor.
• Squamous cell carcinoma.
• Small cell carcinoma.
• Leiomyosarcoma.

What is staging and how is it performed?

Staging is a way to find out if and where the cancer has spread in your body. Your provider will have you get a few tests to figure out the stage of your cancer. For gastric cancer, these tests may be:

Physical Exam: This is a general exam to look at your body and to talk about past health issues.

Imaging: Radiology tests can look inside your body at the cancer and see if it has spread. These tests can include:

• X-ray.
• CAT scan (CT scan).
• Positron emission tomography scan (PET scan).
• Magnetic resonance imaging (MRI).
• Barium swallow and/or endoscopic ultrasound.

Laboratory Testing: Blood tests such as blood chemistry, a complete blood count, CEA (carcinoembryonic antigen) assay and testing for blood in the stool may be recommended.

Procedures: Each case of gastric cancer is different. Talk with your care team about which procedures may be part of your treatment plan. These options may include:

• Upper Endoscopy (esophagogastroduodenoscopy or EGD): A thin lighted tube with a camera is passed into the throat, esophagus, stomach, and the upper part of the small intestine (the duodenum). A biopsy (see below) may be taken.
• Biopsy: A biopsy takes cells from the cancer, or a piece of the cancer, to see what type of cancer it is and how it behaves. A doctor called a pathologist looks at the sample under a microscope in a laboratory.
• Exploratory Surgery: Several small incisions (cuts) are made to insert a thin, lighted tube with a camera, and several other surgical tools into the abdomen (belly). The surgeon can then see the abdominal organs, take a biopsy, and do a peritoneal wash where the belly is flushed with saline, and the fluid is removed to see if there are cancer cells in the fluid.

Gastric cancer spreads to other parts of the body through the tissue, lymph, and blood systems. Cancer stage determines how extensive the cancer is, how far it has spread, and what treatment course will be recommended. Gastric cancer is described as stages 0 (most limited) through stage IV disease (most advanced).

Surgical Procedures for Gastric Cancer Treatment

Surgery is often used to treat gastric cancers. The procedure used will depend on many factors, including the size and location of the cancer. Your care team will talk to you about your specific procedure. You may have other treatments like chemotherapy and radiation before or after surgery. 

Surgical procedures include:

• Endoscopic resection: An endoscope (thin, lighted tube and other surgical tools) is used to remove the cancerous area, as well as some nearby normal tissue. This is used for those with early stage cancers.
• Subtotal (partial) gastrectomy: The cancerous part of the stomach is removed. In some cases, the lower part of the esophagus, the fatty abdominal covering (called the omentum), the spleen, lymph nodes, and other affected organs are also removed.
• Total gastrectomy: The entire stomach is removed, as well as surrounding tissues, lymph nodes, spleen, and parts of the esophagus and small intestine. After the stomach is removed, the small intestine and esophagus are connected to help with eating and swallowing.
• Feeding tube placement: A feeding tube may be needed to help patients with proper nutrition.
• Other surgeries:
  • Gastrojejunostomy (Gastric Bypass): The part of the small intestine called the jejunum is attached to the top part of the stomach.
  • Endoscopic tumor ablation (endoluminal laser): Uses an endoscope with a laser to remove or kill the cancerous tumor in cases when a tumor bleeds or is blocking an area.
  • Placement of a stent: A stent may be needed to keep the top or bottom part of the stomach open. A hollow, metal tube is placed in the stomach openings so that food can move through.

What are the risks associated with gastric cancer surgery?

As with any surgery, there are risks and possible side effects. These can be:

• Bleeding.
• Blood clots.
• Damage to nearby organs.
• Infection.
• Leakage from the suture lines that connect organs.
• Dumping syndrome which can cause heartburn, nausea, flushing, abdominal pain, diarrhea, dizziness, lightheadedness, increased heart rate, hunger, sweating, weakness, and fatigue.
• Vitamin deficiencies, specifically vitamin B12.

What is recovery like?

Recovery from gastric cancer surgery will depend on the extent of the procedure you have had. At times, a hospital stay is needed.

You will be told how to care for your incisions, drains, or tubes and will be given any other instructions before leaving the hospital.

Your medical team will discuss with you the medications you will be taking, such as those for pain, blood clot, infection, and constipation prevention and/or other conditions.

Precautions after surgery will depend on whether you had one large incision (cut) or many smaller incisions. Often, after partial or total gastrectomy, you will be instructed to:

• Avoid heavy lifting, pushing, pulling, or sports activities until you are told otherwise.
• Showering instead of a bath. Avoid tub bathing or sauna use until the incision is fully healed.
• Avoid driving while using narcotics to manage your pain.
• Increase your daily physical activity as tolerated and rest as needed.

Contact your healthcare team if you experience:

• Fever. Your team will tell you at what temperature they should be contacted.
• Redness, swelling, worsening pain, or drainage from the incision.
• Nausea, vomiting, and/or diarrhea that does not get better.
• Constipation with no bowel movement for 3 days.

How can I care for myself?

You may need a family member or friend to help you with your daily tasks until you are feeling better. It may take some time before your team tells you that you can go back to your normal activity.

Be sure to take your prescribed medications as directed to prevent pain, infection and/or constipation. Call your team with any new or worsening symptoms.

There are ways to manage constipation after your surgery. You can change your diet, drink more fluids, and take over-the-counter medications. Talk with your care team before taking any medications for constipation.

Taking deep breaths and resting can help manage pain, keep your lungs healthy after anesthesia, and promote good drainage of lymphatic fluid. Try to do deep breathing and relaxation exercises a few times a day in the first week, or when you notice you are extra tense.

• Example of a relaxation exercise: While sitting, close your eyes and take 5-10 slow deep breaths. Relax your muscles. Slowly roll your head and shoulders.

This article contains general information. Please be sure to talk to your care team about your specific plan and recovery.