Stomach cancer surgery

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Parminder Dhingra, M.D. [2] Mohammed Abdelwahed M.D[3]

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Surgery is the mainstay of treatment for stomach cancer. Endoscopic resection is suggested for early gastric cancer. There are criteria for endoscopic resection of ealry gastric cancer. Methods for endoscopic resection include endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). Side effects of endoscopy includes bleeding and perforation. For T1 tumors, a 2cm macroscopic resection of tumor margin should be performed. Proximal margin of at least 3 cm is recommended for T2 or deeper tumors with an expansive growth pattern and 5 cm for those with an infiltrative growth pattern. 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 a R0 resection. There is a debate about optimal lymph node removal. D1 lymphadenectomy refers to a dissection of only the perigastric lymph nodes. D2 lymphadenectomy is an extended lymph node dissection, includes removal of nodes along the hepatic, left gastric, celiac, and splenic arteries, as well as those in the splenic hilum. D3 dissection is a super-extended lymphadenectomy. The surgery includes D2 lymphadenectomy plus the removal of nodes within the porta hepatis and periaortic regions.

Surgical Management Of Early Gastric Cancer

Standard criteria for endoscopic resection:

The standard criteria for lesions qualifying for endoscopic resection are the following:[2][3]

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) No ulcer or ulcer scar

5) No venous or lymphatic involvement

Expansion of the criteria to involve more tumors eligible for endoscopic resection was suggested by Japanese centers and these criteria include:[4]

Methods of endoscopic resection

The following are the different types of endoscopic resection techniques for gastric cancer:[5]

  • Endoscopic submucosal dissection (ESD):
    • The mucosa surrounding the lesion is incised using a high-frequency electric knife.
    • ESD is more likely to result in complete resection of early gastric cancer but requires more time and endoscopic skills.

Side effects and complications:

  • Perforation rate for ESD is 4.5 percent, compared with 1.0 percent for EMR.[7]
  • Tumor location in the upper stomach and size more than 2 cm have been associated with an increased risk of perforation with ESD.
  • Treatment of a perforation is endoscopic clipping, open or laparoscopic surgery in case of failed clipping.

Curative resection

The following criteria need to be fulfilled to consider endoscopic resection curative:[8]

Any resection that does not satisfy any of the above criteria is considered non-curative.

Management of non-curative resection 

Management of positive margins[10]

  • Patients with only positive lateral margins can be managed with endoscopic therapy rather than surgery.
  • Almost 90 percent of lateral postitve margins were followed endoscopically with no recurrences.
  • Patients with positive vertical margins, submucosal invasion, or lymphovascular invasion, are treated by surgery.

Local recurrence after EMR/ESD

Local mucosal recurrence after EMR/ESD for tumors that had fulfilled the criteria for indication for endoscopic resection may be treated by another ESD.[11]

Follow-up after endoscopic resection

Follow-up after curative resection
Follow-up after non-curative resection

Surgical Management Of Invasive Gastric Cancer

Surgical management of a gastric tumor with resection of adjacent lymph nodes presents the best chance for long-term survival.

Types of gastric surgery

Curative surgery

  • Modified surgery: The extent of gastric resection and lymphadenectomy is reduced if compared to standard surgery.
  • Extended surgery
  • Gastrectomy with resection of adjacent involved organs

Non-curative surgery

Surgeries 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 with a portion of the antrum
  • Proximal gastrectomy: Stomach resection including the cardia. The pylorus is preserved
  • Segmental gastrectomy: Circumferential resection of the stomach preserving the cardia and pylorus
  • Local resection
  • Non-resectional surgery (bypass surgery, gastrostomy, and jejunostomy)

Determination of gastric resection

  • For T1 tumors, a gross resection margin of 2 cm should be obtained.
  • Proximal margin of at least 3 cm is recommended for T2 or deeper tumors with an expansive growth pattern and 5 cm for those with an infiltrative growth pattern.
  • 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 a R0 resection.
  • 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 the surgery[12][13]

  • The standard surgical procedure is total or distal gastrectomy.
  • Pancreaticosplenectomy
  • Total gastrectomy with splenectomy
  • Esophagectomy and proximal gastrectomy
    • It should be considered for adenocarcinoma located on the proximal side of the esophagogastric junction.
  • Pylorus-preserving gastrectomy
    • For tumors in the middle portion of the stomach with the distal tumor border at least 4 cm proximal to the pylorus.
  • Vagal nerve preservation
    • It is reported that preservation of the hepatic branch of the anterior vagus and the celiac branch of the posterior vagus contributes to improving postoperative quality of life through reducing post-gastrectomy gallstone formation, diarrhea and weight loss. In case of PPG, the hepatic branch should be preserved to maintain the pyloric function.
  • Omentectomy
    • Removal of the greater omentum is usually integrated into the standard gastrectomy for T3 or deeper tumors.

For T1/T2 tumors, the omentum more than 3 cm away from the gastroepiploic arcade may be preserved.

Lymph nodes resection

  • One of the most controversial areas in the surgical management of gastric cancer is the optimal extent of lymph node dissection.[15]
  • The draining lymph nodes 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.[16]

D1 lymphadenectomy

  • It refers to a dissection of only the perigastric lymph nodes.
  • A D1 lymphadenectomy is indicated for T1a tumors that do not meet the criteria for EMR/ ESD and for T1bN0 tumors that are histologically of differentiated type and 1.5 cm or smaller in diameter.

D2 lymphadenectomy

D3 dissection

  • It is a superextended lymphadenectomy. The surgery includes D2 lymphadenectomy plus the removal of nodes within the porta hepatis and periaortic regions.[17]

Local palliative preocedures

  • Endoscopic laser therapy[22]
    • Laser photocoagulation can be effective, particularly for large tumors with diffuse bleeding.
    • An alternative that is being used increasingly is argon plasma coagulation.

Reconstruction after gastrectomy

Total gastrectomy

  • Roux-en-Y esophagojejunostomy[23]
  • Jejunal interposition
  • Double tract method

Distal gastrectomy

Pylorus-preserving gastrectomy[25]

Video shows gastrectomy steps


Gastric cancer treatment algorithm

Gastic carcinoma
Endoscopic resection
Gastrectomy,combined resection,D2
Chemotherapy,Radiptherapy,Palliative surgery


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