Stomach cancer surgery: Difference between revisions

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{{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 management of early gastric cancer ==
== 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)
*[[Endoscopy|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 [[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>


Endoscopic resection is suggested for:
=== Standard criteria for endoscopic resection: ===
* Patients without suspected lymph node involvement
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>
* 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. [1,2]


==== Standard criteria for endoscopic resection: ====
'''1)''' Confined to the [[Mucosal|mucosa]]
1) Confined to the mucosa


2) Smaller than 2 cm for superficially elevated type lesions  
'''2)''' Smaller than 2 cm for superficially elevated type lesions  


3) Smaller than 1 cm for the flat and depressed type lesions
'''3)''' Smaller than 1 cm for the flat and depressed type lesions


4) Without ulcer or ulcer scar  
'''4)''' No [[ulcer]] or [[ulcer]] [[scar]]


5) Without venous or lymphatic involvement [3-7]
'''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 [8-11]. [8,12,13]
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 mucosal tumors of any size
* Differentiated type without [[ulceration]], and [[Mucous membrane|mucosal]] [[tumors]] of any size
* Differentiated type, with ulceration, and mucosal tumors less than 30 mm
* Differentiated type, with [[ulceration]], and [[mucosal]] [[tumors]] less than 30 mm
* Undifferentiated type, without ulceration, and mucosal tumors 20 mm in size or smaller
* Undifferentiated type, without ulceration, and mucosal [[tumors]] 20 mm in size or smaller
In a Japanese report of 131 patients with differentiated mucosal early gastric cancer less than 2 cm, the 5- and 10-year overall survival rates were 84 and 64 percent, respectively. The disease-specific survival rates at both 5- and 10-year follow-up were 99 percent [14].


==== Methods of endoscopic resection ====
=== Methods of endoscopic resection ===
* Endoscopic mucosal resection (EMR): The lesion, together with the surrounding mucosa, is lifted by submucosal injection of saline and removed using a high-frequency steel snare.
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 circumferentially incised using a high-frequency electric knife. 37
* '''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.


* ESD is more likely to result in complete resection of early gastric cancer [36]
=== Side effects and complications: ===
* ESD requires more procedure time and endoscopic skill


==== Side effects and complications: ====
====== '''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]]
* [[Antithrombotic medication|Antithrombotic drug]] therapy is a [[risk factor]] for delayed [[bleeding]]
* [[Bleeding]] treatment is injection therapy, [[electrocoagulation]], ligation with a detectable [[Snare device|snare]], and [[endoscopic]] clipping.


===== '''Bleeding''' =====
====== '''Perforation''' ======
* Bleeding was observed in 30 percent of cases.  [119].
* [[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 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.  


* A tumor size of more than 4 cm is a risk factor for acute bleeding and antithrombotic drug therapy is a risk factor for delayed bleeding.
=== Curative resection ===
* Bleeding treatment is injection therapy, electrocoagulation, ligation with a detectable snare, and endoscopic clipping.
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
===== '''Perforation''' =====
* [[Tumor]] size < 2 cm
* Perforation rate for ESD is 4.5 percent, compared with 1.0 percent for EMR [89].
* [[Histologically]] of [[Differentiation|differentiated]] type
* Tumor location in the upper stomach and  size more than 2 cm have been associated with an increased risk of perforation with ESD. [124].
* Staging of [[tumor]] < T1a
* Treatment of a perforation is endoscopic clipping, open or laparoscopic surgery in case of failed clipping. [122,123].  
 
==== Curative resection ====
Criteria need to be fulfilled to consider endoscopic resection curative:
* En bloc resection
* Tumor size < 2 cm
* Histologically of differentiated type
* Staging of tumor < T1a
* Negative horizontal margin
* Negative horizontal margin
* Negative vertical margin
* Negative vertical margin
* No lymphovascular infiltration  
* 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.


==== '''Managing noncurative resection''' ====
=== '''Management of non-curative resection''' ===
* There is no standard approach for managing these patients noncurative resection. Gastrectomy has been recommended especially for tumors associated with a higher risk for lymph node metastases.
*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 for such patients [42].  
*[[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 non-curative [[Endoscopic surgery|endoscopic resection]] for early gastric cancer had [[lymph node]] [[metastasis]] after the procedure.
* Seven percent of patients who had gastrectomy and lymph node dissection after noncurative endoscopic resection for early gastric cancer had lymph node metastasis after that. [40]


==== '''Positive margins management''' ====
=== '''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 '''lateral margins''' can be managed with further endoscopic therapy rather than surgery. Almost 90 percent of lateral psotitve margins were followed endoscopically with no recurrences.
* Patients with only positive lateral margins can be managed with [[endoscopic]] therapy rather than surgery.  
* Patients with positive '''vertical margins''', submucosal invasion, or lymphovascular invasion, are treated by surgery.[16]
* Almost 90 percent of lateral postitve margins were followed [[Endoscopic|endoscopically]] with no recurrences.
* Patients with positive vertical margins, [[submucosal]] invasion, or lymphovascular invasion, are treated by [[surgery]].


==== Local recurrence after EMR/ESD ====
=== Local recurrence after EMR/ESD ===
Local mucosal recurrence after EMR/ESD for tumors that had fulfilled the absolute indication could be considered to meet the criteria for expanded indication and may be treated by another ESD.  
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>


=== Treatments after endoscopic resection ===
=== Follow-up after endoscopic resection ===


===== Treatments after curative 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 examined and eradicated.
*[[Helicobacter pylori]] should be tested and treated if found.


===== Treatment after non-curative resection =====
===== 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 management of invasive gastric cancer ==
== Surgical Management Of Invasive Gastric Cancer ==
Surgical eradication of a gastric tumor with resection of adjacent lymph nodes represents the best chance for long-term survival.
[[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''': It is the principal surgical procedure performed with curative intent. It involves resection of at least two-thirds of the stomach with a D2 lymph node dissection. In the standard gastrectomy, two-thirds of the stomach is resected.
* '''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/or lymphadenectomy is altered according to tumor stages.
* '''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 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 combined resection of adjacent involved organs  
* Gastrectomy with resection of adjacent involved [[organs]]


* Gastrectomy with extended lymphadenectomy exceeding D2
* [[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. Gastrojejunostomy has been reported to result in superior function compared to simple gastrojejunostomy [2].
* '''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 aims to prolong survival or to delay the onset of symptoms 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 along 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 (esophagogastric junction). 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'''
* '''Non-resectional surgery''' (bypass surgery, [[gastrostomy]], and jejunostomy)


* '''Local resection'''.
==== Determination of gastric resection ====
* '''Non-resectional surgery''' (bypass surgery, gastrostomy, jejunostomy).
* 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.
* 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 [[Endoscopy|endoscopic]] marking by clips of the [[tumor]] border based on [[biopsy]] results will be helpful for decision making regarding the resection line.


==== Determination of gastric resection ====
==== 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>''' ====
* For T1 tumors, a gross resection margin of '''2 cm''' should be obtained.
* The standard surgical procedure is total or distal [[gastrectomy]].
* Proximal margin of at least '''3 cm''' is recommended for T2 or deeper tumors with an expansive growth pattern (types 1 and 2) and '''5 cm''' for those with an infiltrative growth pattern (types 3 and 4).
* '''Pancreaticosplenectomy'''  
* 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 an R0 resection.
**[[Pancreas|Pancreatic]] invasion by tumor requires total [[gastrectomy]] regardless of the [[tumor]] location.  
* 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.
* '''Total gastrectomy with splenectomy'''
**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'''  
**It should be considered for [[adenocarcinoma]] located on the proximal side of the esophagogastric junction.
* '''Pylorus-preserving gastrectomy'''
**For [[Tumor|tumors]] in the middle portion of the stomach with the distal [[tumor]] border at least 4 cm proximal to the [[pylorus]].


==== Selection of the surgery ====
* '''Vagal nerve preservation'''
* The standard surgical procedure for clinically node-positive (N+) or T2-T4a tumors is either total or distal gastrectomy.
**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.
* Distal gastrectomy is selected when a satisfactory proximal resection margin can be obtained.
* '''Omentectomy'''
* Pancreatic invasion by tumor requiring pancreaticosplenectomy necessitates total gastrectomy regardless of the tumor location.
**Removal of the [[greater omentum]] is usually integrated into the standard gastrectomy for T3 or deeper [[Tumor|tumors]].  
* Total gastrectomy with splenectomy should be considered for tumors that are located along the greater curvature and harbor metastasis to no. 4 lymph nodes, even if the primary tumor could be removed by distal gastrectomy.
For T1/T2 tumors, t[[Omentum|he omentum]] more than 3 cm away from the gastroepiploic arcade may be preserved.
* For adenocarcinoma located on the proximal side of the esophagogastric junction, esophagectomy and proximal gastrectomy with gastric tube reconstruction should be considered, similarly to surgery for esophageal cancer.
* '''[[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>
* For T1N0 tumors, the following types of gastric resection can be considered according to tumor location:
**[[Bursectomy]] is removal of the inner [[Peritoneum|peritonea]]<nowiki/>l surface of the [[bursa omentalis]].
* 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.
**It should be avoided in T1/T2 [[tumors]] to prevent injury to the pancreas and adjacent [[blood vessels]].  
* Proximal gastrectomy: for proximal tumors where more than half of the distal stomach can be preserved.
**There are some survival benefits for [[bursectomy]] in T3/T4a [[tumors]].
* Segmental gastrectomy and local resection under sentinel navigation are still regarded as investigational treatments.


=== 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. [46].  
* 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 [47].  
* 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''' refers to a limited dissection of only the perigastric lymph nodes. It is indicated for T1N0 tumors other than the above. A D1 lymphadenectomy is indicated for T1a tumors that do not meet the criteria for EMR/ ESD and for cT1bN0 tumors that are histologically of differentiated type and 1.5 cm or smaller in diameter.  
'''D1 lymphadenectomy'''  
* '''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 (stations 1 to 11). It is indicated for potentially curable T2-T4 tumors as well as T1N+ tumors. A D2 lymphadenectomy should be performed whenever nodal involvement is suspected.  
* It refers to a dissection of only the perigastric [[Lymph node|lymph nodes]].  
* '''D3 dissection''' is a superextended lymphadenectomy. The surgery includes D2 lymphadenectomy plus the removal of nodes within the porta hepatis and periaortic regions (stations 1 to 16) [48].  
* 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'''  
=== Miscellaneous procedures ===
* 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]].  
'''Vagal nerve preservation'''
* It is indicated for potentially curable T2-T4 tumors.  
 
* A D2 [[lymphadenectomy]] should be performed whenever nodal involvement is suspected.
It is reported that preservation of the hepatic branch of the anterior vagus and/or the celiac branch of the posterior vagus contributes to improving postoperative quality of life through reducing post-gastrectomy gallstone formation, diarrhea and/or weight loss. In case of PPG, the hepatic branch should be preserved to maintain the pyloric function.
'''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>
'''Omentectomy'''
 
Removal of the greater omentum is usually integrated in the standard gastrectomy for T3 (SS) or deeper tumors. For T1/T2 tumors, the omentum more than 3 cm away from the gastroepiploic arcade may be preserved.
 
'''Bursectomy'''
 
For tumors penetrating the serosa of the posterior gastric wall, bursectomy (removal of the inner peritoneal surface of the bursa omentalis) may be performed with the aim of removing microscopic tumor deposits in the lesser sac. There is no evidence that bursectomy reduces peritoneal or local recurrence, and it should be avoided in T1/T2 tumors to prevent injury to the pancreas and/or adjacent blood vessels. A small-scale randomized controlled trial recently suggested a survival benefit for bursectomy in T3/T4a tumors
 
=== '''THERAPEUTIC OPTIONS FOR LOCAL PALLIATION''' ===
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. [6-10]
 
two-year survival for chemotherapy alone versus gastrectomy plus chemotherapy was 32 versus 25 percent. 11
 
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 [12].  
 
palliative gastrojejunostomy for patients with metastatic gastric cancer is reserved for cases where less invasive methods cannot be used.
 
'''Endoscopic stent placement''' 
 
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
=== 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.


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 [14].  
* '''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]].


'''Endoscopic laser therapy'''  [22-24]  
* '''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.


Laser photocoagulation can be effective, particularly for large tumors with diffuse bleeding [25,26].
* '''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.


 An alternative that is being used increasingly is argon plasma coagulation. 
* '''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.


=== Reconstruction after gastrectomy ===
=== Reconstruction after gastrectomy ===
'''Total gastrectomy'''
'''Total gastrectomy'''
* Roux-en-Y esophagojejunostomy
* Roux-en-Y esophagojejunostomy<ref name="pmid26379405">{{cite journal| author=Xiao JW, Liu ZL, Ye PC, Luo YJ, Fu ZM, Zou Q et al.| title=Clinical comparison of antrum-preserving double tract reconstruction vs roux-en-Y reconstruction after gastrectomy for Siewert types II and III adenocarcinoma of the esophagogastric junction. | journal=World J Gastroenterol | year= 2015 | volume= 21 | issue= 34 | pages= 9999-10007 | pmid=26379405 | doi=10.3748/wjg.v21.i34.9999 | pmc=4566393 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26379405  }}</ref>
* Jejunal interposition
* Jejunal interposition
* Double tract method
* Double tract method
'''Distal gastrectomy'''
'''Distal gastrectomy'''
* Billroth I gastroduodenostomy
* 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'''
'''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 ==
{{familytree/start}}
{{familytree/start}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | | |A01=Gastic carcinoma}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | | |A01=Gastic carcinoma}}
{{familytree | | | | | | | | | | | | | | | | | | | |,|-|-|-|^|-|-|-|-|-|.| | |}}
{{familytree | | | | | | | | | | | | | | | | | | | |,|-|-|-|^|-|-|-|-|-|-|.| |}}
{{familytree | | | | | | | | | | | | | | | | | | | B01 | | | | | | | | B02 |B01=M0|B02=M1}}
{{familytree | | | | | | | | | | | | | | | | | | | B01 | | | | | | | | | B02 |B01=M0|B02=M1}}
{{familytree | | | | | | | | | | | | |,|-|-|-|-|-|-|+|-|-|-|-|-|-|.| | |!| |}}
{{familytree | | | | | | | | | | | | |,|-|-|-|-|-|-|+|-|-|-|-|-|-|.| | | |!| |}}
{{familytree | | | | | | | | | | | | D01 | | | | | D02 | | | | | D03 | |!| |D01=T1|D02=T2,T3,T4A|D03=T4B}}
{{familytree | | | | | | | | | | | | D01 | | | | | D02 | | | | | D03 | | |!| |D01=T1|D02=T2,T3,T4A|D03=T4B}}
{{familytree | | | | | | | | | | |,|-|^|-|-|-|.| | |!| | | | | | |!| | |!| |}}
{{familytree | | | | | | | | | | |,|-|^|-|-|-|.| | |!| | | | | | |!| | | |!| |}}
{{familytree | | | | | | | | | | E01 | | | | E02 | |!| | | | | | |!| | |!| |E01=N0|E02=N1}}
{{familytree | | | | | | | | | | E01 | | | | E02 |.|!| | | | | | |!| | | |!| |E01=N0|E02=N1}}
{{familytree | | | | | | |,|-|-|-|^|-|-|-|.| | | | |!| | | | | | |!| | |!| | | | | | | | | | | | | | |}}
{{familytree | | | | | | |,|-|-|-|^|-|-|-|.| | | |!|!| | | | | | |!| | | |!| |}}
{{familytree | | | | | | F01 | | | | | | F02 | | | |!| | | | | | |!| | |!| | | | | | | | | |F01=T1a|F02=T1b}}
{{familytree | | | | | | F01 | | | | | | F02 | | |!|!| | | | | | |!| | | |!| |F01=T1a|F02=T1b}}
{{familytree | | | | | | |!| | | | | | | |!| | | | |!| | | | | | |!| | |!| | | | | | | | |}}
{{familytree | | | | | | |!| | | | | | | |!| | | |!|!| | | | | | |!| | | |!| |}}
{{familytree | | | | | | G02 | | | | | | G02 | | | |!| | | | | | |!| | |!| | | | | | | | | | |G01=Differentiated,≤2cm|G02=Differenitated,≤1.5cm}}
{{familytree | | | | | | G02 | | | | | | G02 | | |!|!| | | | | | |!| | | |!| |G01=Differentiated,≤2cm|G02=Differenitated,≤1.5cm}}
{{familytree | | | | |,|-|^|-|.| | | |,|-|^|-|.| | |!| | | | | | |!| | |!| | | | | | | | | | |}}
{{familytree | | | | |,|-|^|-|.| | | |,|-|^|-|.| |!|!| | | | | | |!| | | |!| |}}
{{familytree | | | | H01 | | H02 | | H03 | | H04 | |!| | | | | | |!| | |!| | | | | | | |H01=H01|H02=H02|H03=H03|H04=H04|}}
{{familytree | | | | H01 | | H02 | | H03 | | H04 |!|!| | | | | | |!| | | |!| |H01=Yes|H02=No|H03=Yes|H04=No|}}
{{familytree | | | | |!| | | |!| | | |!| | | |!| | |!| | | | | | |!| | |!| | | | | | | | |}}
{{familytree | | | | |!| | | |`|-|v|-|'| | | |!| |`|(| | | | | | |!| | | |!| |}}
{{familytree | | | | | | | | |`|-|!|-|'| | | | | | | | | | | |}}
{{familytree | | | | I01 | | | | I02 | | | |I03| |I04| | | | I05 | | | I06 | |I01=Endoscopic resection|I02=Gastrectomy,D1|I03=Gastrectomy,D+1|I04=Gastrectomy,D2|I05=Gastrectomy,combined resection,D2|I06=Chemotherapy,Radiptherapy,Palliative surgery}}
{{familytree/end}}
{{familytree/end}}


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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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

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:

Bleeding
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]

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

{{#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

  1. ↑ 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.
  2. ↑ 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.
  3. ↑ 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.
  4. ↑ 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.
  5. ↑ Pimentel-Nunes P, Dinis-Ribeiro M, Ponchon T, Repici A, Vieth M, De Ceglie A; et al. (2015). "Endoscopic submucosal dissection: European Society of Gastrointestinal Endoscopy (ESGE) Guideline". Endoscopy. 47 (9): 829–54. doi:10.1055/s-0034-1392882. PMID 26317585.
  6. ↑ Nishide N, Ono H, Kakushima N, Takizawa K, Tanaka M, Matsubayashi H; et al. (2012). "Clinical outcomes of endoscopic submucosal dissection for early gastric cancer in remnant stomach or gastric tube". Endoscopy. 44 (6): 577–83. doi:10.1055/s-0031-1291712. PMID 22402983.
  7. ↑ Abe Y, Inamori M, Iida H, Endo H, Akiyama T, Yoneda K; et al. (2009). "Clinical characteristics of patients with gastric perforation following endoscopic submucosal resection for gastric cancer". Hepatogastroenterology. 56 (91–92): 921–4. PMID 19621730.
  8. ↑ Japanese Gastric Cancer Association (2017). "Japanese gastric cancer treatment guidelines 2014 (ver. 4)". Gastric Cancer. 20 (1): 1–19. doi:10.1007/s10120-016-0622-4. PMC 5215069. PMID 27342689.
  9. ↑ FLY OA, PRIESTLEY JT, COMFORT MW, GAGE RP (May 1958). "Total gastrectomy: mortality and survival". Ann. Surg. 147 (5): 760–8, discussion 768–70. PMC 1450692. PMID 13521695.
  10. ↑ Wang SY, Yeh CN, Lee HL, Liu YY, Chao TC, Hwang TL, Jan YY, Chen MF (October 2009). "Clinical impact of positive surgical margin status on gastric cancer patients undergoing gastrectomy". Ann. Surg. Oncol. 16 (10): 2738–43. doi:10.1245/s10434-009-0616-0. PMID 19636636.
  11. ↑ Chaves DM, Maluf Filho F, de Moura EG, Santos ME, Arrais LR, Kawaguti F, Sakai P (April 2010). "Endoscopic submucosal dissection for the treatment of early esophageal and gastric cancer--initial experience of a western center". Clinics (Sao Paulo). 65 (4): 377–82. doi:10.1590/S1807-59322010000400005. PMC 2862673. PMID 20454494.
  12. ↑ Kim JY, Ha TK, le Roux CW (2014). "Metabolic effects of gastrectomy with or without omentectomy in gastric cancer". Hepatogastroenterology. 61 (134): 1830–4. PMID 25436387.
  13. ↑ Japanese Gastric Cancer Association (2017). "Japanese gastric cancer treatment guidelines 2014 (ver. 4)". Gastric Cancer. 20 (1): 1–19. doi:10.1007/s10120-016-0622-4. PMC 5215069. PMID 27342689.
  14. ↑ Hirao M, Kurokawa Y, Fujita J, Imamura H, Fujiwara Y, Kimura Y; et al. (2015). "Long-term outcomes after prophylactic bursectomy in patients with resectable gastric cancer: Final analysis of a multicenter randomized controlled trial". Surgery. 157 (6): 1099–105. doi:10.1016/j.surg.2014.12.024. PMID 25704429.
  15. ↑ Noguchi Y, Yoshikawa T, Tsuburaya A, Motohashi H, Karpeh MS, Brennan MF (2000). "Is gastric carcinoma different between Japan and the United States?". Cancer. 89 (11): 2237–46. PMID 11147594.
  16. ↑ Japanese Gastric Cancer Association (2011). "Japanese classification of gastric carcinoma: 3rd English edition". Gastric Cancer. 14 (2): 101–12. doi:10.1007/s10120-011-0041-5. PMID 21573743.
  17. ↑ Sasako M, Sano T, Yamamoto S, Kurokawa Y, Nashimoto A, Kurita A; et al. (2008). "D2 lymphadenectomy alone or with para-aortic nodal dissection for gastric cancer". N Engl J Med. 359 (5): 453–62. doi:10.1056/NEJMoa0707035. PMID 18669424.
  18. ↑ Kikuchi S, Arai Y, Kobayashi N, Tsukamoto H, Shimao H, Sakakibara Y; et al. (2000). "Is extended lymphadenectomy valuable in palliatively gastrectomized patients with gastric cancer and simultaneous peritoneal metastasis?". Hepatogastroenterology. 47 (32): 563–6. PMID 10791239.
  19. ↑ Ouchi K, Sugawara T, Ono H, Fujiya T, Kamiyama Y, Kakugawa Y; et al. (1998). "Therapeutic significance of palliative operations for gastric cancer for survival and quality of life". J Surg Oncol. 69 (1): 41–4. PMID 9762890.
  20. ↑ Jeurnink SM, van Eijck CH, Steyerberg EW, Kuipers EJ, Siersema PD (2007). "Stent versus gastrojejunostomy for the palliation of gastric outlet obstruction: a systematic review". BMC Gastroenterol. 7: 18. doi:10.1186/1471-230X-7-18. PMC 1904222. PMID 17559659.
  21. ↑ Wu KL, Tsao WL, Shyu RY (2000). "Low-power laser therapy for gastrointestinal neoplasia". J Gastroenterol. 35 (7): 518–23. PMID 10905359.
  22. ↑ Freitas D, Gouveia H, Sofia C, Cabral JP, Donato A (1995). "Endoscopic Nd-YAG laser therapy as palliative treatment for esophageal and cardial cancer". Hepatogastroenterology. 42 (5): 633–7. PMID 8751226.
  23. ↑ Xiao JW, Liu ZL, Ye PC, Luo YJ, Fu ZM, Zou Q; et al. (2015). "Clinical comparison of antrum-preserving double tract reconstruction vs roux-en-Y reconstruction after gastrectomy for Siewert types II and III adenocarcinoma of the esophagogastric junction". World J Gastroenterol. 21 (34): 9999–10007. doi:10.3748/wjg.v21.i34.9999. PMC 4566393. PMID 26379405.
  24. ↑ Byun C, Cui LH, Son SY, Hur H, Cho YK, Han SU (2016). "Linear-shaped gastroduodenostomy (LSGD): safe and feasible technique of intracorporeal Billroth I anastomosis". Surg Endosc. 30 (10): 4505–14. doi:10.1007/s00464-016-4783-3. PMID 26895918.
  25. ↑ Song P, Lu M, Pu F, Zhang D, Wang B, Zhao Q (2014). "Meta-analysis of pylorus-preserving gastrectomy for middle-third early gastric cancer". J Laparoendosc Adv Surg Tech A. 24 (10): 718–27. doi:10.1089/lap.2014.0123. PMID 25243417.

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