Gastric Cancer Surgery
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Gastric cancer is a cancer that develops from the lining of the stomach. The stomach is a muscular bag that attaches to the food pipe and at the other end to the intestine. It helps to mix and break down food prior to it entering the intestine. The majority of gastric cancers are adenocarcinomas (90%). Less common primary malignancies include, in order of frequency: gastro-intestinal stromal tumours, carcinoid tumours and lymphomas.
It is the fourth most common cancer in males and fifth most common cancer in females and is the second largest cause of cancer related deaths worldwide. Around 6,700 people are diagnosed with stomach cancer in the UK each year. It is more common in men than women.
It is the fourth most common cancer in males and fifth most common cancer in females and is the second largest cause of cancer related deaths worldwide. Around 6,700 people are diagnosed with stomach cancer in the UK each year. It is more common in men than women.
Risk factors for gastric cancer include Helicobacter pylori infection, cigarette smoking, high alcohol intake, excess dietary salt, inadequate fruit and vegetable consumption, pernicious anaemia and blood group A.
Hereditary gastric cancers are typically of the diffuse or Linitis Plastica histological type, as opposed to the more common intestinal histologic type. It has been estimated that 1–3% of stomach cancers occur as a result of inherited stomach cancer predisposition syndromes.
Signs and symptoms may remain absent during the early stages of gastric cancer, making diagnosis difficult. UK guidelines recommended that patients aged 55 years or more with new onset dyspepsia and all those with alarm symptoms should undergo urgent (within two weeks) upper gastrointestinal endoscopy.
• Dyspepsia - includes a broad range of symptoms including recurrent epigastric pain, heart burn, bloating, nausea or vomiting.
Alarm Symptoms:
• Unintended weight loss
• Upper or lower gastrointestinal bleeding
• Progressive dysphagia (food getting stuck on swallowing)
• Unexplained iron deficiency anaemia
• Persistent vomiting
• Palpable abdominal mass
• Jaundice
Upper Gastro-intestinal Endoscopy and biopsy is the investigation of choice for diagnosis of gastric cancer. A minimum of 6 biopsies is recommended for accurate histological confirmation. Endoscopy can also be augmented by Chromoendoscopy and Narrow Band Imaging (NBI).
Treatment recommendations will be undertaken by a dedicated Upper Gastrointestinal Multi-disciplinary team (MDT). The team meets once a week to discuss patients with oesophageal and gastric cancers to ensure the correct treatment is given. The MDT is attended by multiple specialists including: Medical Oncologists, Clinical Oncologists, Radiologists, Surgeons, Gastroenterologists, Histopathologist, and Specialist Nurses.
The decision for treatment will fall into two categories: treatment with an intent to cure and treatment with an intent to palliate (not curative with an intended purpose to extend life and relieve symptoms). This decision is based on the findings of the staging investigations, patient co-morbidities, nutritional status and patient preferences.
Curative treatment often involves Chemo/radiotherapy in combination with surgery in an attempt to improve survival. Median Five year survival of treatment with curative intent is approximately 45-50%.
The purpose of pre-treatment staging is to identify the depth of infiltration of the tumour into the oesophageal wall (T stage), the presence of regional lymph node metastases (N stage) and distant metastases (M stage). A combination of imaging modalities is used to determine the TNM stage. The TNM Stage can then be used to select appropriate patients for curative or palliative treatment modalities. Metastases is the spread of tumour to sites away from the primary tumour.
• CT (Computer tomography) of the chest/abdomen/pelvis
CT is often the initial staging investigation and takes about 15 minutes to perform. It is useful for detecting metastases in solid organs and distant lymph nodes. Detection is dependent on size of the lesion and there are also limitations in distinguishing metastatic from inflammatory enlargement.
• FDG-PET-CT (18F-fluoro-2-deoxy-D-glucose - Positron Emission Tomography - Computed Tomography)
Cancers preferentially uptake glucose for their metabolism. FDG-PET-CT involves injecting radio-labelled glucose into the bloodstream to highlight foci of cancer in the body. The procedure is very similar to CT but takes longer and you will be asked to starve for 6 hours before hand
• Endoscopic ultrasound (EUS)
This is a similar procedure to the endoscopy, except the probe has an ultrasound device on the end, which enables the doctor to examine the cancer and surrounding tissue in precise detail. It takes longer than an endoscopy and may require more sedation. EUS is the preferred imaging technique for clarification of the T stage and local lymph node involvement. In addition suspicious lymph nodes can be biopsied for histological confirmation.
• Staging laparoscopy
A keyhole examination of the abdomen under general anaesthetic is used for the detection of metastases that cannot be detected with scans. It also allows the surgeon to look at local invasion of the tumour into surrounding organs. The procedure is quick and patients usually go home on the same day.
Gastrectomy is a surgical operation to remove the whole (Total Gastrectomy) or part (Partial Gastrectomy) of the stomach. This is performed in combination with removal of the regional lymph nodes for the purpose of cancer treatment. After removal of part or the whole stomach, the gastrointestinal tract is reconstituted by using the small intestine. This is often termed a Roux-en-Y reconstruction. This a major operation performed under General Anaesthetic and can be undertaken through a classical open approach or using minimally invasive techniques such as laparoscopy or Robotics. Minimal invasive approaches have been shown to reduce pulmonary complications and the overall rate of recovery.
Gastrectomy is a major operation with a significant risk of morbidity. Uncomplicated post-operative hospital stay is approximately 5 to 12 days depending on the type of operation of performed. Potential complications of gastrectomy include: bleeding, infection, anastomotic leak, chyle leak, pulmonary complications, organ impairment, venous thrombo-embolism, dumping syndrome and mortality. Complications will described in more detail by your surgeon and will be addressed promptly if they are to occur in the post-operative period.
To reduce postoperative complications your recovery will be aided by a Prehabilitation Programme and Enhanced Recovery Programme (ERP) designed to speed up your recovery and reduce complications.
After surgery you will be looked after in an intensive care unit for the first 4 to 5 days. You will have several lines for venous and arterial access, an epidural or opioid PCA (patient controlled analgesia) to control your pain, a nasogastric tube, and one or two abdominal drains. These will be removed sequentially over the next few days and your oral liquid and food intake will also be reintroduced. Multiple teams of healthcare professionals will look after you including surgeons, intensivists, nurses, physiotherapists, dieticians, etc, with an aim to re-establish normal function as soon as possible.
Side effects include lethargy during the recovery period, eating problems which may cause weight loss, dumping syndrome which may cause abdominal discomfort and diarrhoea after eating certain foods.
After stomach surgery you may need to take extra calcium, vitamin D and iron. This is because the stomach absorbs these nutrients. You can’t absorb enough from your normal diet without all or most of your stomach. You will no longer be able to take in vitamin B12 from your food without most or all of your stomach. This is because your stomach produces a substance called intrinsic factor that means your body can use vitamin B12. Vitamin B12 helps us maintain a healthy blood supply. You will need vitamin B12 injections every 3 months.
It will take approximately six weeks before achieving good function and three months for full recovery.
For more information:
Cancer Research UK
Macmillan