Stomach cancer surgery
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Parminder Dhingra, M.D. [2]
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Overview
Surgery is the mainstay of treatment for stomach 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)
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. [1,2]
Standard criteria for endoscopic resection:
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) Without ulcer or ulcer scar
5) Without venous or lymphatic involvement [3-7]
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]
- 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
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
- 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.
- Endoscopic submucosal dissection (ESD): The mucosa surrounding the lesion is circumferentially incised using a high-frequency electric knife. 37
- ESD is more likely to result in complete resection of early gastric cancer [36]
- ESD requires more procedure time and endoscopic skill
Side effects and complications:
Bleeding
- Bleeding was observed in 30 percent of cases. [119].
- 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.
- 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 [89].
- Tumor location in the upper stomach and size more than 2 cm have been associated with an increased risk of perforation with ESD. [124].
- 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 vertical margin
- No lymphovascular infiltration
Any resection that does not satisfy any of the above criteria is considered non-curative.
Managing noncurative 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.
- Gastrectomy with removal of perigastric lymph nodes is recommended for such patients [42].
- 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
- 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 positive vertical margins, submucosal invasion, or lymphovascular invasion, are treated by surgery.[16]
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.
Treatments after endoscopic resection
Treatments after curative resection
- Annual endoscopy with abdominal ultrasonography or CT scan follow-up is recommended.
- Helicobacter pylori should be examined and eradicated.
Treatment 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 eradication of a gastric tumor with resection of adjacent lymph nodes represents the best chance for long-term survival.
Types of gastric 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.
- Non-standard gastrectomy: In non-standard gastrectomy, the extent of gastric resection and/or lymphadenectomy is altered according to tumor stages.
- Modified surgery: The extent of gastric resection and lymphadenectomy is reduced compared to standard surgery.
- Extended surgery
- Gastrectomy with combined resection of adjacent involved organs
- Gastrectomy with extended lymphadenectomy exceeding D2
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].
- Reduction surgery: Reduction surgery aims to prolong survival or to delay the onset of symptoms 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 along with a portion of the antrum.
- Proximal gastrectomy: Stomach resection including the cardia (esophagogastric junction). The pylorus is preserved.
- Segmental gastrectomy: Circumferential resection of the stomach preserving the cardia and pylorus.
- Local resection.
- Non-resectional surgery (bypass surgery, gastrostomy, 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 (types 1 and 2) and 5 cm for those with an infiltrative growth pattern (types 3 and 4).
- 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.
- 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
- The standard surgical procedure for clinically node-positive (N+) or T2-T4a tumors is either total or distal gastrectomy.
- Distal gastrectomy is selected when a satisfactory proximal resection margin can be obtained.
- Pancreatic invasion by tumor requiring pancreaticosplenectomy necessitates total gastrectomy regardless of the tumor location.
- 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 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.
- For T1N0 tumors, the following types of gastric resection can be considered according to tumor location:
- 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.
- Proximal gastrectomy: for proximal tumors where more than half of the distal stomach can be preserved.
- Segmental gastrectomy and local resection under sentinel navigation are still regarded as investigational treatments.
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].
- 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].
- 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.
- 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.
- 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].
Miscellaneous procedures
Vagal nerve preservation
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.
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
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].
Endoscopic laser therapy [22-24]
Laser photocoagulation can be effective, particularly for large tumors with diffuse bleeding [25,26].
An alternative that is being used increasingly is argon plasma coagulation.
Reconstruction after gastrectomy
Total gastrectomy
- Roux-en-Y esophagojejunostomy
- Jejunal interposition
- Double tract method
Distal gastrectomy
- Billroth I gastroduodenostomy
- Billroth II gastrojejunostomy
- Roux-en-Y gastrojejunostomy
- Jejunal interposition
Pylorus-preserving gastrectomy
- Gastro-gastrostomy
- Proximal gastrectomy
- Esophagogastrostomy
- Jejunal interposition
- Double tract method
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