Stomach Cancer Surgery

Listed below is the step by step procedure of stomach cancer surgery:

  1. What is Stomach Cancer Surgery?
  2. Why is Stomach Cancer Surgery Required?
  3. Pre-operative Preparation
  4. Day Before Surgery
  5. Procedure Day
  6. Methods/Techniques of Stomach Cancer Surgery
  7. Post Procedure
  8. Risks and Complications

What is Stomach Cancer Surgery?

Stomach cancer is a phenomenon occurring commonly. It occurs in adults usually and in members of both genders. Cancerous affection of practically any organ can occur. Cancer involves rapid spread and multiplication of cells of a particular organ or body system. These cells are however not normal. Their shape, size and functions are distorted. Spread of such cells leads to destruction of the organ or body system involved. Cancer may spread to adjacent organs or invade other body systems. All this necessitates stomach cancer surgery.

stomach cancer surgery

Surgical mode of treatment involves performing procedures to remove the cancerous part of the stomach and surrounding lymph nodes and organs. It may also be done to provide relief to the patient from cancer symptoms.

Why is Stomach Cancer Surgery Required?

The line of treatment for stomach cancer is decided depending on the stage of cancer. Staging is a method to assess the spread and severity of cancer. Cancer of stomach has been classified into 5 stages ranging from 0-4. Following are the indications for stomach surgery:

  • Palliation:
    Cancer is accompanied by growth of tumor. In case of stomach cancer, the tumor may grow and eventually start blocking the passage of food, further into the digestive tract.
  • Other treatment options do not work:
    Surgery is usually not opted as the first line of treatment to cure any condition. In case of cancers, radiation therapy and medicinal therapy are usually opted first. In some cases they may however not work well. This can occur because the cancer has advanced. It can also occur because of contraindications of radiation and medicinal therapy. Then the oncologist may decide to opt for surgery.
  • In conjunction with other therapies:
    In cancer cases, many a times only one mode of therapy will not be sufficient. In this case, surgery may be utilized with either radiotherapy or chemotherapy.
  • Prevent further spread:
    Surgery is at times done to remove lymph nodes adjacent to the stomach which may or may not be affected by cancer yet. Removal of lymph nodes helps to prevent further spread of cancer. Lymph nodes are the most common mode for spread of cancer.

Different types of surgeries are opted for treating cancer of stomach, depending on the stage of cancer. There is a slight difference between surgery and other modes of treatment. Medical therapy or radiation therapy do not need as much extensive pre planning as is needed for surgery. If medical therapy is to be given, the doctor will analyze the case carefully, come to a conclusion and prescribe the best suited medicines.

The doctor does not have to remain seated next to the patient while they take their medicine or continuously monitor them as soon as they take medicine. A follow up on a regular basis suffices usually. During radiation therapy, the doctor will determine the dose and angle of the radiation beams and perform the procedure. He does not need to keep the patient under constant observation except immediately after the procedure.

Surgery is however a different ball-game. It is a longer procedure to be performed. While performing surgery, the doctor has to be present throughout the process. Doctor has to prepare the patient for surgery before hand. Depending on the stage of stomach cancer and associated damage, the type of surgery to be performed is determined. After the surgery, special care has to be taken of the patient. It needs longer planning than other forms of treatment.

Pre-operative Preparation

  • Consent

    Prior to finalizing of surgery as the line of treatment for stomach cancer, the doctor will usually have a detailed discussion about it with the patient and their immediate family. Only in cases where the surgery has to be done under emergency circumstances, the discussion part may tend to get skipped. A consent form has to be signed by the patient and at times, a family member, prior to the surgery.

  • Investigations

    After the decision to proceed with surgery is taken, the patient needs to undergo a battery of medical tests. These tests will determine if the patient is fit to undergo surgery. A blood test is done to determine the levels of hemoglobin, detect the blood group, detect the level of blood sugar. Patients having abnormally high blood sugar levels need to be treated. Surgery can be performed only after blood sugar levels have been normalized. Blood grouping is essential to keep some fresh blood ready for transfusion in case of major blood loss during surgery. An ECG is performed to check cardiac functioning. Lung function tests will be done to assess the respiratory functions of the person.

  • Physical examination

    A detailed physical examination report is prepared for referral of the operating doctor. Blood pressure, body temperature, pulse rate, respiratory function are monitored prior to the surgery. A note will also be made of any medications which the patient might be on for long term. The patient may be taking some medication for other health conditions. A complete list of these medications is submitted to the surgeon. Schedule of these medications may be altered for the duration of surgery. The patient is strictly advised against consumption of alcohol and tobacco well in advance prior to the surgery.

Day Before Surgery

Getting admitted to the hospital at least a day prior to the surgery is advisable. Surgeries for stomach cancer involve accessing the gastrointestinal tract. General anesthesia is used for cancer surgery of stomach. The patient will be completely unconscious during the surgery. Also, the central nervous system is completely under the influence of anethesia.This may cause easy regurgitation of stomach contents into the lungs. Respiratory complications may occur if this happens. Therefore the patient needs to have an empty stomach during surgery.

Laxatives are given to the patient to clear any contents of the digestive tract. Antacids are also given to prevent regurgitation of acid from the stomach into the trachea or lungs.

Procedure Day

On the day of surgery, the patient is wheeled into the operating room which is rid of any infection. Clean and sterile surgical gown and cloth is used to drape the patient. An anesthetist is present in the operating room who decides the details of the anesthesia to be given to the patient. General anesthesia is given in the form of respiratory fumes or injections. Blood pressure, respiratory rate, pulse and body temperature are monitored throughout the surgery. Level of anesthetic medicine is adjusted depending on these parameters.

The skin over the area which is going to be the access point during surgery is cleaned by shaving off all hair over it. A solution of Betadine or some similar antiseptic solution is used to wash the skin. This rids the skin of any microorganisms. A tube is inserted into the trachea via mouth to assist with respiration. After the anesthetist ensures that the patient is completely under control of the anesthesia, stomach cancer surgery begins.

Methods/ Techniques of Stomach Cancer Surgery

Surgery for stomach cancer may be done to remove, the cancerous portion of the stomach only, part of the stomach or the whole stomach. This depends totally on the area which is affected. Surgical methods are as follows:

  • Gastrectomy
  • Endoscopic Mucosal Resection
  • Placement of Feeding Tube
  • Lymphadenectomy
  • Tumor Ablation
  • Gastric Bypass
  • Stent Placement

Gastrectomy

Gastrectomy is the surgery in which part or whole of the stomach is removed. It is known as partial gastrectomy when either the upper or lower part of stomach is involved and the rest of the stomach is healthy. If the upper part of the stomach is removed, then some portion of the lower esophagus can be excised with it. In this case, a vertical single cut is needed to be given on the upper part of abdomen and some part of the chest. Sometimes 2 surgical cuts also may be needed.

If the lower part of the stomach is removed, then some part of the duodenum can be excised. Adjacent lymph nodes can be removed if there is risk of cancer spreading to other organs. If adjacent organs like spleen, liver have been involved the affected parts are excised as well.

If the entire stomach is removed, then the esophagus and the upper part of small intestine are surgically connected to each other. This ensures continuity of the digestive tract. If a part of the stomach is removed, then the remaining part is surgically connected to the esophagus above, or the small intestine below.

Total gastrectomy is done if the cancer has spread through out the stomach.

In partial gastrectomy, the procedure of attaching the remnant part of the stomach to the small intestine is known as 'Billroth' procedure. If the lower portion of the stomach is attached to the duodenum directly, it comprises Billroth I procedure. If this is not possible, Billroth II procedure is performed. In this process, the lose end of the duodenum is tied and secured. The stomach is attached to the small intestine via a hole made in the jejunum.

The surgical incision can be single vertical, two cuts side by side or inverted 'V' shaped on the abdominal skin. Gastrectomy generally takes between 1-3 hours to be successfully completed.

Following are the two ways in which gastrectomy can be done:

  • Open Gastrectomy

    A surgical incision will be made on the abdomen around the stomach. The layers of fat and muscle lying below are carefully cut. Care is taken to avoid damage to the adjoining healthy organs, blood vessels and nerves. The entire stomach or the affected portion of it is removed. Some part of the omentum may also be removed. Omentum is a thick layer supporting the stomach and maintaining its correct position in the digestive tract. The skin which was incised is sealed by stitching it together with a special form of suture or thread.

  • Laparoscopic Gastrectomy

    Laparoscopic surgery differs from open surgery in that, the incision made is relatively very small. Multiple incisions are made to insert the surgical tools. Throughone incision, a camera is inserted which helps the surgeon to visualize the internal structures and operate carefully and correctly. Due to smaller incisions, the blood loss is also lesser as compared to open surgery. Both partial and total gastrectomy can be done laparoscopically.

Endoscopic Mucosal Resection

This form of surgery involves removal of cancerous growth within the stomach along with some part of the stomach wall which is unaffected. This surgery can be effective only if done at very early stages when the cancer is restricted to the internal lining of the stomach. Lymph node involvement should not have taken place.

An endoscope is passed into the stomach via the mouth. Endoscope is a long tube fitted with a video camera at one end. The tube is guided via the mouth into the throat followed by the esophagus from where it finally lands in the stomach. Instruments needed to excise the cancerous tissue can be introduced through the endoscope. The surgeon can visualize clearly the parts to be operated upon due to the video camera.

No surgical incision is needed to be given on the skin during this process. The excised stomach tissue is sent for pathological examination if the oncosurgeon feels the need.

Placement of Feeding Tube

placement of feeding tube

This surgery is usually performed at the time of gastrectomy. If the entire or a considerable part of the stomach is removed, digestion cannot occur in a normal way. Nutritional status of the patient may get hampered. This surgery involves placing a tube into the jejunum which is a part of the small intestine. One end of the tube remains outside the patient's body. Through this end, liquids can directly be introduced into the intestine. This avoids malnutrition which is often observed after gastrectomy.

Lymphadenectomy

The word lymphadenectomy means removal of lymph nodes. Gastrectomy is usually followed by removal of lymph nodes. Lymph nodes are an important route of spread of cancer. Hence, their removal ensures that the cancer does not spread further. Lymph nodes around the stomach are removed; irrespective of whether they are cancerous or not.

Tumor Ablation

In some cases, the cancer may be such that it can be eliminated only to an extent from the stomach. In such cases, surgery can be done for reducing symptoms of the cancer. One such procedure is tumor ablation.

An endoscope is passed up to the stomach and a laser beam is used to vaporize the tumor during this process. This prevents further complications like bleeding from the tumor, blocking of the digestive tract etc. No skin incisions are needed in this process.

This type of treatment forms part of palliative therapy. It lasts for around half an hour.

Gastric Bypass

This surgery is an option when a tumor is present in the lower part of the stomach. It will eventually grow large enough to block the outlet of the stomach. If the patient is fit to tolerate surgery, gastric bypass is one option. This procedure involves connecting the upper part of the stomach to the jejunum. This ensures passage of the food easily to the intestine.

Gastric bypass can be performed by open method or laparoscopic method. The initial process varies for the 2 processes. Open process involves making a single relatively bigger incision on the skin over the abdomen. Laparoscopic method involves making multiple incisions which are relatively smaller. Through one incision a video camera is inserted which helps to visualize the internal structures. The further process is the same for both methods.

The underlying fatty tissue and muscles are cut with the aim to avoid damage to adjacent healthy structures. A portion of the jejunum is carefully incised and connected to the upper stomach via a surgically made incision. After the process is completed the overlying skin is sutured properly. Around 2 hours are needed for completion of gastric bypass.

Stent Placement

Stents are introduced into the digestive tract when there is possibility of the tumor growing and blocking the outlet of the stomach. Aim of the procedure is to keep the outlet patent and prevent blockage of food from passing through. Location of the tumor decides where the stent is to be placed.

The procedure is done endoscopically. Endoscope is a long flexible tube with a camera attached the the end which is introduced inside the stomach. The camera helps visualization of the interior of the stomach. Once the tumor is located, stent is inserted appropriately. Since this is not an open procedure, there is no necessity for any surgical incision on the skin.

Post Procedure

Completion of surgery does not mean that the treatment is over. The patient has to be seen through and cared for till they are discharged from hospital. Medications, and other methods of care ensure speedy recovery. All these factors have been described in detail below

Immediately After Surgery

  • After completion of surgery:

    After surgery, anesthesia is slowly tapered off and completely stopped. The patient is transferred out of the operating room. The bowel movements, blood pressure, pulse, respiratory rate and carefully and regularly monitored. A catheter is placed in the urinary bladder before the surgery It can be retained for 2-3 days. A naso-gastric tube is attached to the patient. It is attached to a suction machine. This machine keeps the stomach empty of all contents. Once bowel sounds return, the tube is removed. Bowel sounds is a normal phenomenon seen in healthy individuals. If a good stethoscope is placed properly on the abdomen of a person, distinct sounds of intestines moving can be heard at regular intervals. During surgery, intestines cease to move temporarily under the effect of general anesthesia. Hence, return of bowel sounds is an indication that the effect of anesthesia has worn off and the digestive tract has resumed normal movement. The respiratory tube can also be removed once normal breathing resumes.

  • Diet for the first few days:

    Liquid diet is given for first few days. If that is tolerated, the patient will be offered simple and soft solid food which is easy to digest.

  • Post operative medicines:

    After surgery, the patient may experience pain on the site of surgery. Patients are also prone to developing infections after surgery. Pain killers and antibiotics are given for these complaints.

  • Home care for first few days:

    The patient can be moving around, a day or two after surgery. The discharge from hospital is dependent on the patient's recovery post surgery. Regular follow up with the doctor at decided intervals is recommended and to be followed. The patient may be recommended to see a dietician who will advise a diet suitable to fulfill all nutritional needs and at the same time easy to consume and digest.

    Along with surgery, radiation therapy and chemotherapy can also be used to treat cancer. All these methods of treatment can be used individually or in conjunction with each other.

Long Term Care

  • Awareness of health

    Once cancer is treated, there is no guarantee that it won't recur. Recurrence however can be avoided if the patient is cautious and watchful of their health. They should be observant about development of any new symptoms. A doctor should be consulted immediately if there is recurrence of old symptoms or development of new ones. Regular follow up should be done for as long as the doctor advises.

  • Diet

    Dietary restrictions are advised to be followed for a long term after recovery. If gastrectomy has been performed, the process of natural digestion gets affected slightly. Patients should avoid eating large quantities of food at a time or food that is very oily and spicy. Total abstinence from alcohol and tobacco is advisable. People who eat meat should restrict its consumption as much as possible as it is heavy to digest.

  • Healthy lifestyle

    To recover from cancer and the treatment which follows, it is essential to adopt a lifestyle inclusive of regular physical exercise, a diet comprising all essential nutrients, getting adequate sleep and avoiding unnecessary stress levels.

Risks and Complications

Cancer is a debilitating (one that makes patient weak) disease. The surgeries employed to treat it also drain substantial energy out of the patient. Following complications may be noticed in patients after treatment:

  1. Allergic reaction to anesthesia may occur. There could be respiratory troubles due to it.
  2. There may be occasional accidental injury to adjacent healthy organs during surgery.
  3. Excessive bleeding can at times occur from the tumor itself or due to accidental injury to adjacent blood vessels. This can also lead to formation of blood clots. In such cases, blood transfusion may be needed. Blood clots have to be surgically removed or can be treated with medicines. However, medicines which dissolve blood clots have to be administered with great caution after stomach cancer surgery to avoid further bleeding.
  4. Nausea, vomiting, pain in the abdomen can be experienced at times. Medications can help to alleviate these symptoms.
  5. The function of stomach includes absorption of vitamin B. Hence, gastrectomy may often lead to deficiency of this vitamin. It can however be reversed with nutritional supplements.
Every case of stomach cancer needs different treatment approach. The same method of surgery cannot be used in each case. The decision related to surgery and other modes of treatment is decided by the oncologist and oncosurgeon based on the patient's age, general health and intensity of cancer. The above information will give you a basic idea about what to expect with regards to surgery for stomach cancer.



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