Stomach cancer surgery: Difference between revisions
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__NOTOC__ | __NOTOC__ | ||
{{CMG}}{{AE}}{{PSD}} | {{CMG}}; {{AE}} {{PSD}} {{MAD}} | ||
{{Stomach cancer}} | {{Stomach cancer}} | ||
==Overview== | ==Overview== | ||
Surgery is the mainstay of treatment for stomach cancer. | [[Surgery]] is the mainstay of treatment for [[stomach cancer]]. [[Endoscopic surgery|Endoscopic resection]] is suggested for early [[gastric cancer]]. There are criteria for [[Endoscopic surgery|endoscopic resection]] of ealry [[gastric cancer]]. Methods for [[Endoscopic surgery|endoscopic resection]] include [[Endoscopic surgery|endoscopic mucosal resection]] (EMR) and [[Endoscopic surgery|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 [[Tumor|tumors]] with an expansive growth pattern and 5 cm for those with an [[Infiltration analgesia|infiltrative]] growth pattern. For [[tumors]] invading the [[Esophagus|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 [[Lymph node|nodes]] along the [[hepatic]], [[Left gastric artery|left gastric]], [[Celiac artery|celiac]], and [[Spleen|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 [[Lymph nodes|nodes]] within the [[porta hepatis]] and periaortic regions. | ||
== Surgical | == Surgical Management Of Early Gastric Cancer == | ||
*Early gastric cancer is an invasive gastric cancer that invades no more than the submucosa whatever the lymph node metastasis condition (T1 and any N) | *Early gastric cancer is an invasive gastric cancer that invades no more than the [[submucosa]] whatever the [[lymph node]] [[metastasis]] condition (T1 and any N) | ||
*Endoscopic resection is suggested for: | *[[Endoscopy|Endoscopic resection]] is suggested for: | ||
**Patients without suspected lymph node involvement | **Patients without suspected [[lymph node]] involvement | ||
**Tumor size <20 mm in diameter | **[[Tumor]] size <20 mm in diameter | ||
**Differentiated intestinal histology | **Differentiated [[intestinal]] [[histology]] | ||
*In most trials, there are no differences in outcome between the surgical and the endoscopic treatment.<ref name="pmid16301028">{{cite journal| author=Etoh T, Katai H, Fukagawa T, Sano T, Oda I, Gotoda T et al.| title=Treatment of early gastric cancer in the elderly patient: results of EMR and gastrectomy at a national referral center in Japan. | journal=Gastrointest Endosc | year= 2005 | volume= 62 | issue= 6 | pages= 868-71 | pmid=16301028 | doi=10.1016/j.gie.2005.09.012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16301028 }}</ref> | *In most trials, there are no differences in outcome between the [[Surgery|surgical]] and the [[Endoscopic surgery|endoscopic treatment]].<ref name="pmid16301028">{{cite journal| author=Etoh T, Katai H, Fukagawa T, Sano T, Oda I, Gotoda T et al.| title=Treatment of early gastric cancer in the elderly patient: results of EMR and gastrectomy at a national referral center in Japan. | journal=Gastrointest Endosc | year= 2005 | volume= 62 | issue= 6 | pages= 868-71 | pmid=16301028 | doi=10.1016/j.gie.2005.09.012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16301028 }}</ref> | ||
==== | === Standard criteria for endoscopic resection: === | ||
The standard criteria for lesions qualifying for endoscopic resection are the following:<ref name="pmid27664260">{{cite journal| author=Smyth EC, Verheij M, Allum W, Cunningham D, Cervantes A, Arnold D et al.| title=Gastric cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. | journal=Ann Oncol | year= 2016 | volume= 27 | issue= suppl 5 | pages= v38-v49 | pmid=27664260 | doi=10.1093/annonc/mdw350 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27664260 }}</ref><ref name="pmid24914327">{{cite journal| author=Bollschweiler E, Berlth F, Baltin C, Mönig S, Hölscher AH| title=Treatment of early gastric cancer in the Western World. | journal=World J Gastroenterol | year= 2014 | volume= 20 | issue= 19 | pages= 5672-8 | pmid=24914327 | doi=10.3748/wjg.v20.i19.5672 | pmc=4024776 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24914327 }}</ref> | |||
''' | '''1)''' Confined to the [[Mucosal|mucosa]] | ||
==== Side effects and complications: | '''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 system|lymphatic]] involvement | |||
Expansion of the criteria to involve more [[tumors]] eligible for endoscopic resection was suggested by Japanese centers and these criteria include:<ref name="pmid23023388">{{cite journal| author=Lee JH, Choi MG, Min BH, Noh JH, Sohn TS, Bae JM et al.| title=Predictive factors for lymph node metastasis in patients with poorly differentiated early gastric cancer. | journal=Br J Surg | year= 2012 | volume= 99 | issue= 12 | pages= 1688-92 | pmid=23023388 | doi=10.1002/bjs.8934 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23023388 }}</ref> | |||
* Differentiated type without [[ulceration]], and [[Mucous membrane|mucosal]] [[tumors]] of any size | |||
* Differentiated type, with [[ulceration]], and [[mucosal]] [[tumors]] less than 30 mm | |||
* Undifferentiated type, without ulceration, and mucosal [[tumors]] 20 mm in size or smaller | |||
=== Methods of endoscopic resection === | |||
The following are the different types of endoscopic resection techniques for gastric cancer:<ref name="pmid26317585">{{cite journal| author=Pimentel-Nunes P, Dinis-Ribeiro M, Ponchon T, Repici A, Vieth M, De Ceglie A et al.| title=Endoscopic submucosal dissection: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. | journal=Endoscopy | year= 2015 | volume= 47 | issue= 9 | pages= 829-54 | pmid=26317585 | doi=10.1055/s-0034-1392882 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26317585 }}</ref> | |||
* '''Endoscopic mucosal resection (EMR)''': | |||
** The lesion and the surrounding [[Mucosal|mucosa]] are lifted by [[Submucosa|submucosal]] injection of [[Saline (medicine)|saline]] and removed using a [[Snare device|steel snare]]. | |||
* '''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: === | |||
====== '''Bleeding''' ====== | ====== '''Bleeding''' ====== | ||
* Bleeding | * [[Bleeding]]<ref name="pmid22402983">{{cite journal| author=Nishide N, Ono H, Kakushima N, Takizawa K, Tanaka M, Matsubayashi H et al.| title=Clinical outcomes of endoscopic submucosal dissection for early gastric cancer in remnant stomach or gastric tube. | journal=Endoscopy | year= 2012 | volume= 44 | issue= 6 | pages= 577-83 | pmid=22402983 | doi=10.1055/s-0031-1291712 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22402983 }}</ref> | ||
* A tumor size of more than 4 cm is a risk factor for acute bleeding | * A [[tumor]] size of more than 4 cm is a [[risk factor]] for acute [[bleeding]] | ||
* Antithrombotic drug therapy is a risk factor for delayed bleeding | * [[Antithrombotic medication|Antithrombotic drug]] therapy is a [[risk factor]] for delayed [[bleeding]] | ||
* Bleeding treatment is injection therapy, electrocoagulation, ligation with a detectable snare, and endoscopic clipping. | * [[Bleeding]] treatment is injection therapy, [[electrocoagulation]], ligation with a detectable [[Snare device|snare]], and [[endoscopic]] clipping. | ||
====== '''Perforation''' ====== | ====== '''Perforation''' ====== | ||
* Perforation rate for ESD is 4.5 percent, compared with 1.0 percent for EMR.<ref name="pmid19621730">{{cite journal| author=Abe Y, Inamori M, Iida H, Endo H, Akiyama T, Yoneda K et al.| title=Clinical characteristics of patients with gastric perforation following endoscopic submucosal resection for gastric cancer. | journal=Hepatogastroenterology | year= 2009 | volume= 56 | issue= 91-92 | pages= 921-4 | pmid=19621730 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19621730 }}</ref> | * [[Perforation]] rate for ESD is 4.5 percent, compared with 1.0 percent for EMR.<ref name="pmid19621730">{{cite journal| author=Abe Y, Inamori M, Iida H, Endo H, Akiyama T, Yoneda K et al.| title=Clinical characteristics of patients with gastric perforation following endoscopic submucosal resection for gastric cancer. | journal=Hepatogastroenterology | year= 2009 | volume= 56 | issue= 91-92 | pages= 921-4 | pmid=19621730 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19621730 }}</ref> | ||
* Tumor location in the upper stomach and | * [[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. | * 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:<ref name="pmid273426892">{{cite journal| author=Japanese Gastric Cancer Association| title=Japanese gastric cancer treatment guidelines 2014 (ver. 4). | journal=Gastric Cancer | year= 2017 | volume= 20 | issue= 1 | pages= 1-19 | pmid=27342689 | doi=10.1007/s10120-016-0622-4 | pmc=5215069 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27342689 }}</ref> | |||
* | * Enbloc resection | ||
* Tumor size < 2 cm | * [[Tumor]] size < 2 cm | ||
* Histologically of differentiated type | * [[Histologically]] of [[Differentiation|differentiated]] type | ||
* Staging of tumor < T1a | * Staging of [[tumor]] < T1a | ||
* Negative horizontal margin | * Negative horizontal margin | ||
* Negative vertical margin | * Negative vertical margin | ||
* No | * No [[lymphatic]] or [[vascular]] infiltration | ||
Any resection that does not satisfy any of the above criteria is considered non-curative. | Any resection that does not satisfy any of the above criteria is considered non-curative. | ||
=== '''Management of non-curative resection''' === | |||
*There is no standard approach for managing patients with | *There is no standard approach for managing patients with non-curative resection. [[Gastrectomy]] has been recommended especially for [[tumors]] associated with a higher risk for [[lymph node]] [[metastases]]. | ||
*Gastrectomy with removal of perigastric lymph nodes is recommended. | *[[Gastrectomy]] with removal of perigastric [[lymph nodes]] is recommended.<ref name="pmid13521695">{{cite journal |vauthors=FLY OA, PRIESTLEY JT, COMFORT MW, GAGE RP |title=Total gastrectomy: mortality and survival |journal=Ann. Surg. |volume=147 |issue=5 |pages=760–8; discussion 768–70 |date=May 1958 |pmid=13521695 |pmc=1450692 |doi= |url=}}</ref> | ||
* Seven percent of patients who had gastrectomy and lymph node dissection after | * Seven percent of patients who had [[gastrectomy]] and [[lymph node]] dissection after non-curative [[Endoscopic surgery|endoscopic resection]] for early gastric cancer had [[lymph node]] [[metastasis]] after the procedure. | ||
=== '''Management of positive margins'''<ref name="pmid19636636">{{cite journal |vauthors=Wang SY, Yeh CN, Lee HL, Liu YY, Chao TC, Hwang TL, Jan YY, Chen MF |title=Clinical impact of positive surgical margin status on gastric cancer patients undergoing gastrectomy |journal=Ann. Surg. Oncol. |volume=16 |issue=10 |pages=2738–43 |date=October 2009 |pmid=19636636 |doi=10.1245/s10434-009-0616-0 |url=}}</ref> === | |||
* Patients with only positive | * Patients with only positive lateral margins can be managed with [[endoscopic]] therapy rather than surgery. | ||
* Almost 90 percent of lateral | * Almost 90 percent of lateral postitve margins were followed [[Endoscopic|endoscopically]] with no recurrences. | ||
* Patients with positive | * 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 | Local [[mucosal]] recurrence after EMR/ESD for [[tumors]] that had fulfilled the criteria for indication for [[Endoscopic surgery|endoscopic resection]] may be treated by another ESD.<ref name="pmid20454494">{{cite journal |vauthors=Chaves DM, Maluf Filho F, de Moura EG, Santos ME, Arrais LR, Kawaguti F, Sakai P |title=Endoscopic submucosal dissection for the treatment of early esophageal and gastric cancer--initial experience of a western center |journal=Clinics (Sao Paulo) |volume=65 |issue=4 |pages=377–82 |date=April 2010 |pmid=20454494 |pmc=2862673 |doi=10.1590/S1807-59322010000400005 |url=}}</ref> | ||
=== | === Follow-up after endoscopic resection === | ||
===== | ===== Follow-up after curative resection ===== | ||
*Annual endoscopy with abdominal ultrasonography or CT scan follow-up is recommended. | *Annual [[endoscopy]] with [[abdominal]] [[Ultrasound|ultrasonography]] or [[Computed tomography|CT]] scan follow-up is recommended. | ||
*Helicobacter pylori should be tested and treated if found. | *[[Helicobacter pylori]] should be tested and treated if found. | ||
===== | ===== Follow-up after non-curative resection ===== | ||
*Surgical treatment should be performed after non-curative resection such as endoscopic coagulation using a laser or argon-plasma coagulator. | *[[Surgery|Surgical]] treatment should be performed after non-curative resection such as [[endoscopic]] [[coagulation]] using a laser or [[Argon plasma coagulation|argon-plasma coagulator]]. | ||
== Surgical | == Surgical Management Of Invasive Gastric Cancer == | ||
Surgical | [[Surgery|Surgical]] management of a gastric [[tumor]] with resection of adjacent [[lymph nodes]] presents the best chance for long-term survival. | ||
=== Types of gastric surgery === | === Types of gastric surgery === | ||
==== Curative surgery ==== | ==== Curative surgery ==== | ||
* '''Standard gastrectomy''': In the standard gastrectomy, two-thirds of the stomach is resected. It is the principal surgical procedure used. | * '''Standard gastrectomy''': In the standard [[Gastrectomy|gastrectomy,]] two-thirds of the [[stomach]] is [[Resection|resected]]. It is the principal surgical procedure used. | ||
* '''Non-standard gastrectomy''': In non-standard gastrectomy, the extent of gastric resection and lymphadenectomy is altered according to tumor | * '''Non-standard gastrectomy''': In non-standard [[gastrectomy]], the extent of [[gastric]] [[resection]] and [[lymphadenectomy]] is altered according to the stage of [[tumor]]. | ||
* '''Modified surgery:''' The extent of gastric resection and lymphadenectomy is reduced if compared to standard surgery. | * '''Modified surgery:''' The extent of gastric resection and [[lymphadenectomy]] is reduced if compared to standard [[surgery]]. | ||
* '''Extended surgery''' | * '''Extended surgery''' | ||
* Gastrectomy with resection of adjacent involved organs | * Gastrectomy with resection of adjacent involved [[organs]] | ||
* Gastrectomy with extended lymphadenectomy | * [[Gastrectomy]] with extended [[lymphadenectomy]] | ||
==== Non-curative surgery ==== | ==== Non-curative surgery ==== | ||
* '''Palliative surgery:''' Palliative gastrectomy or gastrojejunostomy is selected depending on the resectability of the primary tumor and surgical risks to relieve symptoms such as bleeding or obstruction. | * '''Palliative surgery:''' Palliative [[gastrectomy]] or [[gastrojejunostomy]] is selected depending on the resectability of the primary [[tumor]] and surgical risks to relieve symptoms such as [[bleeding]] or [[Obstruction|obstruction.]] | ||
* '''Reduction surgery:''' Reduction surgery aim is to prolong survival by reducing tumor volume. | * '''Reduction surgery:''' Reduction surgery aim is to prolong survival by reducing [[tumor]] volume. | ||
=== Surgeries for gastric cancer === | === Surgeries for gastric cancer === | ||
* '''Total gastrectomy''': Total resection of the stomach '''including the cardia''' and pylorus | * '''Total gastrectomy''': Total resection of the stomach '''including the [[cardia]]''' and [[pylorus]] | ||
* '''Distal gastrectomy:''' Stomach resection including the pylorus. The '''cardia is preserved''' | * '''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 | * '''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 | * '''Proximal gastrectomy''': [[Stomach]] resection including the [[cardia]]. The [[pylorus]] is preserved | ||
* '''Segmental gastrectomy:''' Circumferential resection of the stomach preserving the cardia and pylorus | * '''Segmental gastrectomy:''' Circumferential resection of the [[stomach]] preserving the [[cardia]] and [[pylorus]] | ||
* '''Local resection''' | * '''Local resection''' | ||
* '''Non-resectional surgery''' (bypass surgery, gastrostomy, and jejunostomy) | * '''Non-resectional surgery''' (bypass surgery, [[gastrostomy]], and jejunostomy) | ||
==== Determination of gastric resection ==== | ==== Determination of gastric resection ==== | ||
* For '''T1''' tumors, a gross resection margin of '''2 cm''' should be obtained. | * For '''T1''' [[Tumor|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. | * 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. | * For tumors invading the [[esophagus]], a '''5-cm''' margin is not necessarily required, but [[Frozen section procedure|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. | * When the [[tumor]] border is unclear, preoperative [[Endoscopy|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'''<ref name="pmid25436387">{{cite journal| author=Kim JY, Ha TK, le Roux CW| title=Metabolic effects of gastrectomy with or without omentectomy in gastric cancer. | journal=Hepatogastroenterology | year= 2014 | volume= 61 | issue= 134 | pages= 1830-4 | pmid=25436387 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25436387 }}</ref><ref name="pmid27342689">{{cite journal| author=Japanese Gastric Cancer Association| title=Japanese gastric cancer treatment guidelines 2014 (ver. 4). | journal=Gastric Cancer | year= 2017 | volume= 20 | issue= 1 | pages= 1-19 | pmid=27342689 | doi=10.1007/s10120-016-0622-4 | pmc=5215069 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27342689 }}</ref>''' ==== | ==== Selection of the surgery'''<ref name="pmid25436387">{{cite journal| author=Kim JY, Ha TK, le Roux CW| title=Metabolic effects of gastrectomy with or without omentectomy in gastric cancer. | journal=Hepatogastroenterology | year= 2014 | volume= 61 | issue= 134 | pages= 1830-4 | pmid=25436387 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25436387 }}</ref><ref name="pmid27342689">{{cite journal| author=Japanese Gastric Cancer Association| title=Japanese gastric cancer treatment guidelines 2014 (ver. 4). | journal=Gastric Cancer | year= 2017 | volume= 20 | issue= 1 | pages= 1-19 | pmid=27342689 | doi=10.1007/s10120-016-0622-4 | pmc=5215069 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27342689 }}</ref>''' ==== | ||
* The standard surgical procedure is total or distal gastrectomy. | * The standard surgical procedure is total or distal [[gastrectomy]]. | ||
* '''Pancreaticosplenectomy''' | * '''Pancreaticosplenectomy''' | ||
**Pancreatic invasion by tumor requires total gastrectomy regardless of the tumor location. | **[[Pancreas|Pancreatic]] invasion by tumor requires total [[gastrectomy]] regardless of the [[tumor]] location. | ||
* '''Total gastrectomy with splenectomy''' | * '''Total gastrectomy with splenectomy''' | ||
**It should be considered for tumors that are located along the greater curvature with metastasis to no. 4 lymph nodes. | **It should be considered for [[Tumor|tumors]] that are located along the greater curvature with [[metastasis]] to no. 4 [[Lymph node|lymph nodes]]. | ||
* '''Esophagectomy and proximal gastrectomy''' | * '''Esophagectomy and proximal gastrectomy''' | ||
**It should be considered for adenocarcinoma located on the proximal side of the esophagogastric junction. | **It should be considered for [[adenocarcinoma]] located on the proximal side of the esophagogastric junction. | ||
* '''Pylorus-preserving gastrectomy''' | * '''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. | **For [[Tumor|tumors]] in the middle portion of the stomach with the distal [[tumor]] border at least 4 cm proximal to the [[pylorus]]. | ||
* '''Vagal nerve preservation''' | * '''Vagal nerve preservation''' | ||
**It is reported that preservation of the hepatic branch of the anterior vagus and | **It is reported that preservation of the hepatic branch of the anterior [[Vagus nerve|vagus]] and the celiac branch of the posterior [[Vagus nerve|vagus]] contributes to improving postoperative quality of life through reducing [[post-gastrectomy]] [[Gallstone disease|gallstone]] formation, [[diarrhea]] and [[weight loss]]. In case of PPG, the hepatic branch should be preserved to maintain the [[Pylorus|pyloric]] function. | ||
* '''Omentectomy''' | * '''Omentectomy''' | ||
**Removal of the greater omentum is usually integrated into the standard gastrectomy for T3 or deeper tumors. | **Removal of the [[greater omentum]] is usually integrated into the standard gastrectomy for T3 or deeper [[Tumor|tumors]]. | ||
For T1/T2 tumors, | For T1/T2 tumors, t[[Omentum|he omentum]] more than 3 cm away from the gastroepiploic arcade may be preserved. | ||
* '''Bursectomy'''<ref name="pmid25704429">{{cite journal| author=Hirao M, Kurokawa Y, Fujita J, Imamura H, Fujiwara Y, Kimura Y et al.| title=Long-term outcomes after prophylactic bursectomy in patients with resectable gastric cancer: Final analysis of a multicenter randomized controlled trial. | journal=Surgery | year= 2015 | volume= 157 | issue= 6 | pages= 1099-105 | pmid=25704429 | doi=10.1016/j.surg.2014.12.024 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25704429 }}</ref> | * '''[[Bursectomy]]'''<ref name="pmid25704429">{{cite journal| author=Hirao M, Kurokawa Y, Fujita J, Imamura H, Fujiwara Y, Kimura Y et al.| title=Long-term outcomes after prophylactic bursectomy in patients with resectable gastric cancer: Final analysis of a multicenter randomized controlled trial. | journal=Surgery | year= 2015 | volume= 157 | issue= 6 | pages= 1099-105 | pmid=25704429 | doi=10.1016/j.surg.2014.12.024 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25704429 }}</ref> | ||
**Bursectomy is removal of the inner | **[[Bursectomy]] is removal of the inner [[Peritoneum|peritonea]]<nowiki/>l surface of the [[bursa omentalis]]. | ||
**It should be avoided in T1/T2 tumors to prevent injury to the pancreas and | **It should be avoided in T1/T2 [[tumors]] to prevent injury to the pancreas and adjacent [[blood vessels]]. | ||
**There are some survival benefits for bursectomy in T3/T4a tumors. | **There are some survival benefits for [[bursectomy]] in T3/T4a [[tumors]]. | ||
=== Lymph nodes resection === | === Lymph nodes resection === | ||
* One of the most controversial areas in the surgical management of gastric cancer is the optimal extent of lymph node dissection.<ref name="pmid11147594">{{cite journal| author=Noguchi Y, Yoshikawa T, Tsuburaya A, Motohashi H, Karpeh MS, Brennan MF| title=Is gastric carcinoma different between Japan and the United States? | journal=Cancer | year= 2000 | volume= 89 | issue= 11 | pages= 2237-46 | pmid=11147594 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11147594 }}</ref> | * One of the most controversial areas in the surgical management of gastric cancer is the optimal extent of [[lymph node]] dissection.<ref name="pmid11147594">{{cite journal| author=Noguchi Y, Yoshikawa T, Tsuburaya A, Motohashi H, Karpeh MS, Brennan MF| title=Is gastric carcinoma different between Japan and the United States? | journal=Cancer | year= 2000 | volume= 89 | issue= 11 | pages= 2237-46 | pmid=11147594 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11147594 }}</ref> | ||
* 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.<ref name="pmid21573743">{{cite journal| author=Japanese Gastric Cancer Association| title=Japanese classification of gastric carcinoma: 3rd English edition. | journal=Gastric Cancer | year= 2011 | volume= 14 | issue= 2 | pages= 101-12 | pmid=21573743 | doi=10.1007/s10120-011-0041-5 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21573743 }}</ref> | * The draining [[Lymph node|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]].<ref name="pmid21573743">{{cite journal| author=Japanese Gastric Cancer Association| title=Japanese classification of gastric carcinoma: 3rd English edition. | journal=Gastric Cancer | year= 2011 | volume= 14 | issue= 2 | pages= 101-12 | pmid=21573743 | doi=10.1007/s10120-011-0041-5 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21573743 }}</ref> | ||
'''D1 lymphadenectomy''' | '''D1 lymphadenectomy''' | ||
* It refers to a dissection of only the perigastric lymph nodes. | * It refers to a dissection of only the perigastric [[Lymph node|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. | * A D1 [[lymphadenectomy]] is indicated for T1a [[Tumor|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''' | '''D2 lymphadenectomy''' | ||
* It 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. | * It is an extended [[lymph node]] dissection, includes removal of nodes along the [[hepatic]], [[Left gastric artery|left gastric]], [[Celiac artery|celiac]], and [[Spleen|splenic]] arteries, as well as those in the [[splenic hilum]]. | ||
* It is indicated for potentially curable T2-T4 tumors. | * It is indicated for potentially curable T2-T4 tumors. | ||
* A D2 lymphadenectomy should be performed whenever nodal involvement is suspected. | * A D2 [[lymphadenectomy]] should be performed whenever nodal involvement is suspected. | ||
'''D3 dissection''' | '''D3 dissection''' | ||
* It is a superextended lymphadenectomy. The surgery includes D2 lymphadenectomy plus the removal of '''nodes within the porta hepatis and periaortic regions.'''<ref name="pmid18669424">{{cite journal| author=Sasako M, Sano T, Yamamoto S, Kurokawa Y, Nashimoto A, Kurita A et al.| title=D2 lymphadenectomy alone or with para-aortic nodal dissection for gastric cancer. | journal=N Engl J Med | year= 2008 | volume= 359 | issue= 5 | pages= 453-62 | pmid=18669424 | doi=10.1056/NEJMoa0707035 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18669424 }}</ref> | * It is a superextended lymphadenectomy. The surgery includes D2 lymphadenectomy plus the removal of '''nodes within the [[porta hepatis]] and periaortic regions.'''<ref name="pmid18669424">{{cite journal| author=Sasako M, Sano T, Yamamoto S, Kurokawa Y, Nashimoto A, Kurita A et al.| title=D2 lymphadenectomy alone or with para-aortic nodal dissection for gastric cancer. | journal=N Engl J Med | year= 2008 | volume= 359 | issue= 5 | pages= 453-62 | pmid=18669424 | doi=10.1056/NEJMoa0707035 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18669424 }}</ref> | ||
=== Local palliative preocedures=== | === Local palliative preocedures=== | ||
Therapeutic options to control symptoms of local disease progression, such as nausea, pain, bleeding, and obstruction, include palliative surgical resection, surgical bypass (gastrojejunostomy), radiation therapy (RT), and endoscopic techniques | * Therapeutic options to control [[symptoms]] of local [[disease]] progression, such as [[nausea]], [[pain]], [[bleeding]], and [[obstruction]], include [[palliative]] surgical [[resection]], [[surgical]] bypass ([[gastrojejunostomy]]), [[radiation therapy]] (RT), and [[endoscopic]] techniques. | ||
patients undergoing gastrectomy had a significantly higher incidence of several serious adverse events related to chemotherapy, including leucopenia, nausea, anorexia, and hyponatremia. | * '''Palliative resection''' | ||
**[[Palliative]] [[gastrectomy]] should be reserved for extreme, highly [[symptomatic]] cases where less invasive methods cannot be used.<ref name="pmid10791239">{{cite journal| author=Kikuchi S, Arai Y, Kobayashi N, Tsukamoto H, Shimao H, Sakakibara Y et al.| title=Is extended lymphadenectomy valuable in palliatively gastrectomized patients with gastric cancer and simultaneous peritoneal metastasis? | journal=Hepatogastroenterology | year= 2000 | volume= 47 | issue= 32 | pages= 563-6 | pmid=10791239 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10791239 }}</ref> | |||
**Two-year survival for [[chemotherapy]] alone versus [[gastrectomy]] plus [[chemotherapy]] was 32 versus 25 percent. | |||
**Patients undergoing [[gastrectomy]] had a significantly higher [[incidence]] of several serious adverse events related to [[chemotherapy]], including [[Leukopenia|leucopenia]], [[nausea]], [[anorexia]], and [[hyponatremia]]. | |||
'''Gastrojejunostomy''' | * '''Gastrojejunostomy''' | ||
**[[Palliative]] [[gastrojejunostomy]] for [[gastric outlet obstruction]] associated with unresectable advanced gastric cancer can improve food intake.<ref name="pmid9762890">{{cite journal| author=Ouchi K, Sugawara T, Ono H, Fujiya T, Kamiyama Y, Kakugawa Y et al.| title=Therapeutic significance of palliative operations for gastric cancer for survival and quality of life. | journal=J Surg Oncol | year= 1998 | volume= 69 | issue= 1 | pages= 41-4 | pmid=9762890 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9762890 }}</ref> | |||
**[[Palliative]] [[gastrojejunostomy]] for patients with [[Metastasis|metastatic]] gastric cancer is reserved for cases where less invasive methods cannot be used. | |||
* '''Endoscopic stent placement<ref name="pmid17559659">{{cite journal| author=Jeurnink SM, van Eijck CH, Steyerberg EW, Kuipers EJ, Siersema PD| title=Stent versus gastrojejunostomy for the palliation of gastric outlet obstruction: a systematic review. | journal=BMC Gastroenterol | year= 2007 | volume= 7 | issue= | pages= 18 | pmid=17559659 | doi=10.1186/1471-230X-7-18 | pmc=1904222 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17559659 }}</ref><ref name="pmid10905359">{{cite journal| author=Wu KL, Tsao WL, Shyu RY| title=Low-power laser therapy for gastrointestinal neoplasia. | journal=J Gastroenterol | year= 2000 | volume= 35 | issue= 7 | pages= 518-23 | pmid=10905359 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10905359 }}</ref>''' | |||
**For [[palliation]] of [[Obstruction|obstructive]] [[symptoms]], [[endoscopic]] placement of a stent provides a less invasive alternative to [[surgery]] for [[symptom]] [[palliation]] and may possibly be more effective in [[symptom]] relief. | |||
**[[Stenting]] may achieve a better [[quality of life]] compared with other forms of [[palliation]]. | |||
**In a review of two randomized trials of [[Endoscopy|endoscopic]] [[stenting]] versus palliative [[Gastrojejunostomy|gastrojejunostomy,]] there were no statistically significant differences between the two procedures in terms of efficacy or complications. | |||
* '''Endoscopic laser therapy<ref name="pmid8751226">{{cite journal| author=Freitas D, Gouveia H, Sofia C, Cabral JP, Donato A| title=Endoscopic Nd-YAG laser therapy as palliative treatment for esophageal and cardial cancer. | journal=Hepatogastroenterology | year= 1995 | volume= 42 | issue= 5 | pages= 633-7 | pmid=8751226 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8751226 }}</ref>''' | |||
**Laser [[photocoagulation]] can be effective, particularly for large [[tumors]] with diffuse [[bleeding]]. | |||
**An alternative that is being used increasingly is argon plasma coagulation. | |||
'''Endoscopic laser therapy | |||
=== Reconstruction after gastrectomy === | === Reconstruction after gastrectomy === | ||
| Line 184: | Line 185: | ||
* Double tract method | * Double tract method | ||
'''Distal gastrectomy''' | '''Distal gastrectomy''' | ||
* Billroth I gastroduodenostomy<ref name="pmid26895918">{{cite journal| author=Byun C, Cui LH, Son SY, Hur H, Cho YK, Han SU| title=Linear-shaped gastroduodenostomy (LSGD): safe and feasible technique of intracorporeal Billroth I anastomosis. | journal=Surg Endosc | year= 2016 | volume= 30 | issue= 10 | pages= 4505-14 | pmid=26895918 | doi=10.1007/s00464-016-4783-3 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26895918 }}</ref> | * Billroth I [[gastroduodenostomy]]<ref name="pmid26895918">{{cite journal| author=Byun C, Cui LH, Son SY, Hur H, Cho YK, Han SU| title=Linear-shaped gastroduodenostomy (LSGD): safe and feasible technique of intracorporeal Billroth I anastomosis. | journal=Surg Endosc | year= 2016 | volume= 30 | issue= 10 | pages= 4505-14 | pmid=26895918 | doi=10.1007/s00464-016-4783-3 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26895918 }}</ref> | ||
* Billroth II gastrojejunostomy | * Billroth II [[gastrojejunostomy]] | ||
* Roux-en-Y gastrojejunostomy | * Roux-en-Y [[gastrojejunostomy]] | ||
* Jejunal interposition | * Jejunal interposition | ||
'''Pylorus-preserving gastrectomy'''<ref name="pmid25243417">{{cite journal| author=Song P, Lu M, Pu F, Zhang D, Wang B, Zhao Q| title=Meta-analysis of pylorus-preserving gastrectomy for middle-third early gastric cancer. | journal=J Laparoendosc Adv Surg Tech A | year= 2014 | volume= 24 | issue= 10 | pages= 718-27 | pmid=25243417 | doi=10.1089/lap.2014.0123 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25243417 }}</ref> | '''Pylorus-preserving gastrectomy'''<ref name="pmid25243417">{{cite journal| author=Song P, Lu M, Pu F, Zhang D, Wang B, Zhao Q| title=Meta-analysis of pylorus-preserving gastrectomy for middle-third early gastric cancer. | journal=J Laparoendosc Adv Surg Tech A | year= 2014 | volume= 24 | issue= 10 | pages= 718-27 | pmid=25243417 | doi=10.1089/lap.2014.0123 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25243417 }}</ref> | ||
* Gastro-gastrostomy | * Gastro-[[gastrostomy]] | ||
* Proximal gastrectomy | * Proximal [[gastrectomy]] | ||
* Esophagogastrostomy | * Esophagogastrostomy | ||
* Jejunal interposition | * Jejunal interposition | ||
* Double tract method | * Double tract method | ||
== Video shows gastrectomy steps == | |||
{{#ev:youtube|5rj7M4kZKp0}} | |||
== Gastric cancer treatment algorithm == | == Gastric cancer treatment algorithm == | ||
Latest revision as of 21:52, 25 January 2019
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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Stomach cancer Microchapters |
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Diagnosis |
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Treatment |
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Case Studies |
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Stomach cancer surgery On the Web |
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American Roentgen Ray Society Images of Stomach cancer surgery |
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Risk calculators and risk factors for Stomach cancer surgery |
Overview
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
- Early gastric cancer is an invasive gastric cancer that invades no more than the submucosa whatever the lymph node metastasis condition (T1 and any N)
- Endoscopic resection is suggested for:
- Patients without suspected lymph node involvement
- Tumor size <20 mm in diameter
- Differentiated intestinal histology
- In most trials, there are no differences in outcome between the surgical and the endoscopic treatment.[1]
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
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]
- Differentiated type without ulceration, and mucosal tumors of any size
- Differentiated type, with ulceration, and mucosal tumors less than 30 mm
- Undifferentiated type, without ulceration, and mucosal tumors 20 mm in size or smaller
Methods of endoscopic resection
The following are the different types of endoscopic resection techniques for gastric cancer:[5]
- Endoscopic mucosal resection (EMR):
- The lesion and the surrounding mucosa are lifted by submucosal injection of saline and removed using a steel snare.
- 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:
Bleeding
- Bleeding[6]
- A tumor size of more than 4 cm is a risk factor for acute bleeding
- Antithrombotic drug therapy is a risk factor for delayed bleeding
- Bleeding treatment is injection therapy, electrocoagulation, ligation with a detectable snare, and endoscopic clipping.
Perforation
- 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]
- Enbloc resection
- Tumor size < 2 cm
- Histologically of differentiated type
- Staging of tumor < T1a
- Negative horizontal margin
- Negative vertical margin
- No lymphatic or vascular infiltration
Any resection that does not satisfy any of the above criteria is considered non-curative.
Management of non-curative resection
- There is no standard approach for managing patients with non-curative resection. Gastrectomy has been recommended especially for tumors associated with a higher risk for lymph node metastases.
- Gastrectomy with removal of perigastric lymph nodes is recommended.[9]
- Seven percent of patients who had gastrectomy and lymph node dissection after non-curative endoscopic resection for early gastric cancer had lymph node metastasis after the procedure.
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
- Annual endoscopy with abdominal ultrasonography or CT scan follow-up is recommended.
- Helicobacter pylori should be tested and treated if found.
Follow-up after non-curative resection
- Surgical treatment should be performed after non-curative resection such as endoscopic coagulation using a laser or argon-plasma coagulator.
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
- Standard gastrectomy: In the standard gastrectomy, two-thirds of the stomach is resected. It is the principal surgical procedure used.
- Non-standard gastrectomy: In non-standard gastrectomy, the extent of gastric resection and lymphadenectomy is altered according to the stage of tumor.
- 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
- Gastrectomy with extended lymphadenectomy
Non-curative surgery
- Palliative surgery: Palliative gastrectomy or gastrojejunostomy is selected depending on the resectability of the primary tumor and surgical risks to relieve symptoms such as bleeding or obstruction.
- Reduction surgery: Reduction surgery aim is to prolong survival by reducing tumor volume.
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
- Pancreatic invasion by tumor requires total gastrectomy regardless of the tumor location.
- Total gastrectomy with splenectomy
- It should be considered for tumors that are located along the greater curvature with metastasis to no. 4 lymph nodes.
- Esophagectomy and proximal gastrectomy
- It should be considered for adenocarcinoma located on the proximal side of the esophagogastric junction.
- Pylorus-preserving gastrectomy
- 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.
- Bursectomy[14]
- Bursectomy is removal of the inner peritoneal surface of the bursa omentalis.
- It should be avoided in T1/T2 tumors to prevent injury to the pancreas and adjacent blood vessels.
- There are some survival benefits for bursectomy in T3/T4a tumors.
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
- It 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.
- It is indicated for potentially curable T2-T4 tumors.
- A D2 lymphadenectomy should be performed whenever nodal involvement is suspected.
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
- Therapeutic options to control symptoms of local disease progression, such as nausea, pain, bleeding, and obstruction, include palliative surgical resection, surgical bypass (gastrojejunostomy), radiation therapy (RT), and endoscopic techniques.
- Palliative resection
- Palliative gastrectomy should be reserved for extreme, highly symptomatic cases where less invasive methods cannot be used.[18]
- Two-year survival for chemotherapy alone versus gastrectomy plus chemotherapy was 32 versus 25 percent.
- Patients undergoing gastrectomy had a significantly higher incidence of several serious adverse events related to chemotherapy, including leucopenia, nausea, anorexia, and hyponatremia.
- Gastrojejunostomy
- Palliative gastrojejunostomy for gastric outlet obstruction associated with unresectable advanced gastric cancer can improve food intake.[19]
- Palliative gastrojejunostomy for patients with metastatic gastric cancer is reserved for cases where less invasive methods cannot be used.
- Endoscopic stent placement[20][21]
- For palliation of obstructive symptoms, endoscopic placement of a stent provides a less invasive alternative to surgery for symptom palliation and may possibly be more effective in symptom relief.
- Stenting may achieve a better quality of life compared with other forms of palliation.
- In a review of two randomized trials of endoscopic stenting versus palliative gastrojejunostomy, there were no statistically significant differences between the two procedures in terms of efficacy or complications.
- 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
- Billroth I gastroduodenostomy[24]
- Billroth II gastrojejunostomy
- Roux-en-Y gastrojejunostomy
- Jejunal interposition
Pylorus-preserving gastrectomy[25]
- Gastro-gastrostomy
- Proximal gastrectomy
- Esophagogastrostomy
- Jejunal interposition
- Double tract method
Video shows gastrectomy steps
{{#ev:youtube|5rj7M4kZKp0}}
Gastric cancer treatment algorithm
| Gastic carcinoma | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| M0 | M1 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| T1 | T2,T3,T4A | T4B | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| N0 | N1 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| T1a | T1b | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Differenitated,≤1.5cm | Differenitated,≤1.5cm | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Yes | No | Yes | No | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Endoscopic resection | Gastrectomy,D1 | Gastrectomy,D+1 | Gastrectomy,D2 | Gastrectomy,combined resection,D2 | Chemotherapy,Radiptherapy,Palliative surgery | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
References
- ↑ Etoh T, Katai H, Fukagawa T, Sano T, Oda I, Gotoda T; et al. (2005). "Treatment of early gastric cancer in the elderly patient: results of EMR and gastrectomy at a national referral center in Japan". Gastrointest Endosc. 62 (6): 868–71. doi:10.1016/j.gie.2005.09.012. PMID 16301028.
- ↑ Smyth EC, Verheij M, Allum W, Cunningham D, Cervantes A, Arnold D; et al. (2016). "Gastric cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up". Ann Oncol. 27 (suppl 5): v38–v49. doi:10.1093/annonc/mdw350. PMID 27664260.
- ↑ Bollschweiler E, Berlth F, Baltin C, Mönig S, Hölscher AH (2014). "Treatment of early gastric cancer in the Western World". World J Gastroenterol. 20 (19): 5672–8. doi:10.3748/wjg.v20.i19.5672. PMC 4024776. PMID 24914327.
- ↑ Lee JH, Choi MG, Min BH, Noh JH, Sohn TS, Bae JM; et al. (2012). "Predictive factors for lymph node metastasis in patients with poorly differentiated early gastric cancer". Br J Surg. 99 (12): 1688–92. doi:10.1002/bjs.8934. PMID 23023388.
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