Stomach cancer surgery: gastrectomy, lymph nodes and life after the operation

A partial (subtotal) gastrectomy is used when the cancer is in the lower stomach; up to two thirds of the stomach is removed, and the small bowel is joined to what remains (Cancer Research UK). A total gastrectomy removes the whole stomach and is often advised for cancers in the upper part near the oesophagus (American Cancer Society).

After a total gastrectomy the oesophagus is joined directly to the small bowel in a Roux-en-Y reconstruction. Cancers where the stomach meets the oesophagus may need an oesophagogastrectomy, which removes the top of the stomach and part of the oesophagus (Cancer Research UK).

Lymph nodes around the stomach and along its main blood vessels are removed and checked; the results confirm the stage and show how well chemotherapy worked (Cancer Research UK). In the United States at least 16 nodes are recommended, called a D1 lymphadenectomy (ACS).

A D2 lymphadenectomy goes further, clearing the nodes along the larger vessels near the stomach. Surgeons in Japan and South Korea have reported very good results with it, and outcomes are better when surgeon and hospital have broad experience (ACS). For less fit patients, only the closest nodes may be taken.

Most people with stomach cancer have perioperative chemotherapy, given before and after surgery, unless the cancer is very early (stage 1A). It aims to shrink the tumour so it is easier to remove and to lower the chance of it returning; FLOT is one of the most common combinations (Cancer Research UK).

Treatment before surgery is called neoadjuvant and treatment afterwards adjuvant (NCI). The medical oncologist chooses the drugs and the number of cycles, and the surgeon plans the operation around them.

The diagnosis is made by gastroscopy and biopsy. Staging then uses a CT scan of the chest, abdomen and pelvis, often an endoscopic ultrasound and a PET-CT, and sometimes a staging laparoscopy, a small keyhole look inside the abdomen for spread (Cancer Research UK).

Surgery with curative intent suits cancer that has not spread to distant organs, in a patient fit enough for a major operation. Very early cancers in the lining may be removed through the endoscope instead (ACS). When cancer has spread, surgery may still relieve a blockage, but its aim is then symptom relief rather than cure (NCI).

Open surgery uses one or more cuts in the abdomen. Keyhole gastrectomy, laparoscopic or robot-assisted, uses 4 to 6 small cuts and is done in specialist centres by trained surgeons; the team chooses the approach from the tumour's type and position (Cancer Research UK).

The surgeon removes the stomach, the fatty apron called the omentum and the lymph nodes, then rebuilds the passage for food. A small feeding tube into the small intestine (J tube) may be placed to protect nutrition, especially if chemotherapy follows (ACS).

Preparation often overlaps with chemotherapy. A dietitian should be part of your team from diagnosis, because keeping weight and strength up makes recovery easier (Cancer Research UK).

You will have blood tests and heart and lung checks, a review of your medicines and a meeting with the surgeon to go through the plan, the consent form and what to expect afterwards. Bring every endoscopy, CT and pathology report so the team works from the full picture.

Most people wake in a high dependency unit and return to the ward within a few days. Sips of water usually start within 24 to 48 hours, small amounts of food within about a week, and most people go home around 9 days after the operation (Cancer Research UK).

If you have a feeding tube, it usually stays for 4 to 6 weeks. Vitamin B12 injections are needed after gastrectomy, usually every 3 months, and tiredness can last several weeks or months (Cancer Research UK).

The biggest change is smaller, more frequent meals; how much you need to adapt depends on how much stomach was removed (ACS). Some people get dumping syndrome, when food passes too quickly into the small bowel and causes faintness, discomfort or diarrhoea soon after eating or a while later (Cancer Research UK).

It helps to eat slowly and rest afterwards, cut down sugary foods, add fibre and avoid soups and very liquid meals. Extra calcium, vitamin D and iron may be needed besides B12 (Cancer Research UK).

Possible problems include bleeding, wound and chest infection, blood clots, reflux and slow emptying, and weight loss (Cancer Research UK). A leak where the new connection is made is rare but serious and needs treatment straight away, sometimes another operation (ACS).

Death from surgery is very uncommon; the risk is higher with more extensive operations and lower with experienced surgeons (ACS).

• Fever, shivering, or redness, swelling or discharge from the wound
• A swollen, hot, red or sore leg
• New or worsening abdominal pain, or being unable to keep fluids down, which can signal a leak
• Weakness that lasts more than a few weeks

Shortness of breath, chest pain, coughing up blood or feeling faint can mean a clot in the lung: go to an emergency department at once (Cancer Research UK).

A GIST is a different tumour that starts in the wall of the digestive tract and is most common in the stomach and small intestine (NCI). Surgery is used for tumours that can be removed, and keyhole surgery may suit tumours of 5 cm or smaller.

GISTs rarely spread to lymph nodes, so a wide node clearance is usually not needed; the aim is to remove the tumour in one piece without breaking its capsule. Large tumours may first be shrunk with a targeted drug such as imatinib (ACS).

Results depend mainly on the stage and on completing the planned treatment. For stage I cancer, the KLASS-01 trial of 1,416 patients found keyhole distal gastrectomy as safe for long-term survival as open surgery (JAMA Oncology 2019).

Your oncologist will explain what your own stage means. Read how the same team approach applies to colon cancer surgery.

Sources: ACS, Cancer Research UK. The choice of operation follows staging and the team meeting.

The cost depends on the hospital and room class, the extent of surgery and the staplers and keyhole instruments used, days in high dependency care and on the ward, and any feeding tube. Staging tests, pathology and follow-up add to it; chemotherapy and its cycles are priced separately.

To discuss your reports and get a current written quote, book a consultation with Dr. Yasser, and ask the clinic about payment options. If you also have a thyroid problem, see thyroid surgery.