Overview of Gastric Resection for Malignancy
Gastric cancer, also known as stomach cancer, ranks as the world’s fifth most common type of cancer and the third leading cause of death from cancer. Every year, over 1 million new cases are diagnosed across the globe, including approximately 27,500 new cases in the U.S. alone. Statistically, with an incidence rate of 5.6% and a death rate of 7.7%, it’s clear that we need more effective ways to manage this disease. In fact, 50-80% of all cases of stomach cancer are considered advanced, meaning they’re harder to control and treat. In many instances, between 35-51% of patients don’t react well to the initial chemotherapy and 15% see their cancer get worse.
Healthcare professionals in Western countries typically use a variety of methods to take this on, blending innovative mixtures of chemotherapy drugs, radiation therapies, and immunomodulatory drugs (medicines that aid your immune system) based on the unique needs of each patient and their specific type of cancer. The goal is to reduce the negative side effects of treatment while maximizing the success of traditional treatment methods. Even with these modern methods, though, the most important aspect of treatment is the complete surgical removal of the tumor along with nearby lymph nodes.
There are multiple options for surgically removing stomach cancer, including removing the entire stomach (total gastrectomy), removing the top half of the stomach (proximal gastrectomy), removing the bottom half of the stomach (distal gastrectomy), and preserving the bottom of the stomach while removing the rest (pylorus-preserving distal gastrectomy). The type of surgery is determined by various factors such as where the tumor is located, how large it is, its histological subtype (cancer cell type), and genomic etiology (genetic cause of the cancer).
As doctors often focus on taking out the tumor, they’ll try to take a good portion of tissue around the tumor and keep a safe distance from the actual tumor edge. This extra effort to achieve an “R0 resection” (removal of all cancer cells) may involve removing other organs, if necessary. After this, they focus on reestablishing safely the continuity of the intestines and bile ducts to ensure proper nutrition for the patient. Some patients with extensive cancer might need additional surgery, such as multivisceral resection (removal of multiple organs) or cytoreductive surgery (reducing the number of cancer cells) along with heated chemotherapy directly into the abdomen (HIPEC).
The traditional method for removing stomach cancer is open gastrectomy. In recent years, though, less invasive surgical methods, such as laparoscopic gastrectomy (surgery using a thin, lighted tube) and robotic-assisted gastrectomy (surgery assisted by a robot) have become more popular. These ones offer advantages such as less complications, quicker recovery, and better-looking scars. The decision on which type of surgery to use is based on various factors like patient characteristics, specifics of the cancer, and the surgeon’s experience. Despite the popularity of the less invasive methods, open gastrectomy is still used in certain cases, highlighting the importance of personalized care in treating stomach cancer.
Since it was first done in 1994, laparoscopic gastrectomy has been a reliable method for treating early stage stomach cancer. Several research studies have shown that the long-term results of laparoscopic gastrectomy are similar to those of open gastrectomy. Therefore, it’s now an accepted method for treating early stage stomach cancer. Moreover, it’s considered to be safe and effective for total removal of locally advanced cancer in the lower part of the stomach. Despite this, there are ongoing discussions about the differences in outcomes and complexity between laparoscopic and open surgery.
Robotic-assisted surgery offers a promising improvement to conventional laparoscopic surgery for treating stomach cancers. It offers benefits such as three-dimensional vision, enhanced skill acquisition, increased dexterity, improved mobility, and better comfort for surgeons. In spite of these advantages, the use of robotic-assisted gastrectomy for removing stomach cancer has been slower compared to other surgical methods. While a limited amount of high-quality data primarily from retrospective studies prevents a comprehensive evaluation of robotic-assisted gastrectomy, it is hoped that further research will shed more light on its long-term results and effectiveness.
While many studies have been conducted on the safety and effectiveness of laparoscopic and robotic-assisted gastrectomy compared to open gastrectomy for removing stomach cancer, there is still no clear consensus. Recent studies reporting short-term results following robotic-assisted gastrectomy have brought a sense of optimism in the surgical community as these minimally invasive methods may improve patient outcomes. However, more research is required to definitively confirm the effectiveness and safety of laparoscopic and robotic-assisted gastrectomy compared to open gastrectomy in treating stomach cancer.
Another emerging procedure for treating early stages of stomach cancer is Endoscopic Submucosal Dissection (ESD), particularly when there’s a low risk of cancer spreading to the lymph nodes. Unlike traditional surgery, ESD is less invasive and offers benefits like preserving the entire stomach and maintaining the patient’s quality of life. Despite some drawbacks, this technique represents significant progress in treating early stage stomach cancer. It offers effective treatment while reducing the impact on patients’ overall well-being.
The shift from traditional open surgical procedures to less invasive methods represents significant progress in treating stomach cancer. These advancements provide patients improved results and a better quality of life. As we continue to explore various surgical methods to treat stomach cancer, it’s important to discuss their advantages, limitations, and emerging trends in the field.
Anatomy and Physiology of Gastric Resection for Malignancy
The stomach plays a crucial role in digestion. It has four main parts:
- The cardia: this part is the first to receive food from the esophagus, which is the tube connecting your mouth and stomach.
- The fundus: this part is like a dome and it rests at the top and to the left of the cardia.
- The body: this is the biggest part of the stomach and it is situated below the fundus.
- The pylorus: This is the part that links the stomach to the duodenum, which is the first part of your small intestine. The pylorus is shaped like a funnel and has two parts, the pyloric antrum, and the pyloric canal. The pyloric antrum joins the body of the stomach to the pyloric canal which further links with the duodenum. The pyloric sphincter, a band of smooth muscle, controls when food leaves the stomach.
The stomach wall consists of five layers:
- The mucosa: This is the innermost layer where most stomach cancers commence. The mucosa consists of three parts – epithelial cells, connective tissue (also called lamina propria), and a thin layer of muscle known as the muscularis mucosa.
- The submucosa: This layer supports the mucosa.
- The muscularis propria: This is a thick muscular layer that helps to mix the food in the stomach and move it along.
- Subserosa
- Serosa: This is the stomach’s outermost layer.
When the stomach is relaxed, the mucosa and submucosa form folds, called rugae.
Various ligaments hold the stomach in place including:
- The gastrocolic ligament: connects the larger curve of the stomach to part of the large intestine called the transverse colon.
- The gastrosplenic ligament: connects the stomach’s larger curve to the spleen.
- The gastrohepatic ligament: connects the liver to the smaller curve of the stomach.
- The gastrophrenic ligament: connects the dome-shaped muscle that helps with breathing (diaphragm) to the top part of the stomach.
The stomach receives blood from:
- The celiac trunk: it comes from a large artery called the abdominal aorta and has three main branches including, left gastric, common hepatic, and splenic arteries.
- The left and right gastric arteries: these run along the upper and lower parts of the smaller curve of the stomach.
- The left and right gastroepiploic arteries: these run along the upper and lower parts of the larger curve of the stomach.
- The short gastric arteries: these supply blood to the larger curve of the stomach.
The lymphatic system in the stomach is quite complex and has 16 areas where lymph nodes cluster. These clusters are categorized into four groups based on their positions relative to the main tumor. A process called lymphadenectomy is used to remove these nodes. The procedure can vary from removing nodes in areas 1 to 6, referred to as D1 lymphadenectomy, or nodes in areas 1 to 11, referred to as a D2 lymphadenectomy. It can even involve removing nodes in all areas (1 to 16) in a process known as a D2+ lymphadenectomy.
Why do People Need Gastric Resection for Malignancy
Gastric resections, or surgeries on the stomach, are used to treat different kinds of stomach problems. Here’s a layman’s explanation of when and why different types of these procedures are done:
Endoscopic Submucosal Dissection (ESD):
ESD is a delicate surgical procedure often used to treat early-stage stomach cancers when it is highly unlikely that the cancer has spread to the lymph nodes. This procedure lets doctors remove larger stomach lesions and look closely at how deep the tumor has invaded and if blood vessels are involved. This technique is usually used in places like Asia, where gastric cancer is more regular.
According to the Japanese Gastric Cancer Treatment Guidelines, lesions with low chances of spreading to lymph nodes, those with differentiation (cells that look a lot like healthy cells) and without ulcer lesions less than or equal to 3 cm in size, as well as differentiated lesions with small ulcer lesions, can be treated with ESD. However, even ESD may not completely cure the cancer in some cases.
Distal Gastrectomy:
This surgery, which removes the lower part of the stomach, is mostly used for middle and lower third of stomach cancers when a safe margin can be kept while leaving an adequate stomach pouch. The requirement for this procedure depends on the stage of cancer and the preference for conservative or less aggressive treatments in early-stage cancers.
Pylorus-Preserving Distal Gastrectomy:
This surgery preserves a part of the stomach named the pylorus while removing some distal or lower part of the stomach. It might have fewer complications, such as reduced bile reflux, fewer gallstones, and less weight loss, but might not provide a thorough lymph node examination. It’s only advised when the tumor is in the middle third of the stomach and has started growing into the stomach wall, and there are no affected lymph nodes or metastasis.
Proximal Gastrectomy:
When the cancer is in the upper third of the stomach, a surgery called proximal gastrectomy may be used. This procedure preserves the lower part of the stomach and pylorus, the opening from the stomach into the small intestine.
Total Gastrectomy:
Total gastrectomy, or the removal of the whole stomach, is recommended when tumors involve a significant part of the upper or middle stomach. This procedure is also needed for far-reaching tumors or those with a specific type of gastric cancer known as signet-ring cell. Patients with specific genetic mutations leading to multiple stomach cancers might also require total gastrectomy.
Lymphadenectomy:
Lymphadenectomy is a procedure that involves removing lymph nodes during gastrectomy, a crucial step for staging or determining the extent of the cancer. There are three types of lymphadenectomies, known as D1, D2, and D3, each involving removing lymph nodes from different key areas around the stomach. Current practice suggests performing a D2 lymph node removal to provide the best chance of survival.
When a Person Should Avoid Gastric Resection for Malignancy
There are certain conditions where a person cannot undergo gastric resection surgery, which is an operation to remove part or all of the stomach. One of these is when a patient is not fit enough to have general anesthesia, which makes you sleep during surgery. This is an absolute requirement for the surgery.
Other relative factors or conditions that may make this surgery risky include being of older age, having severe lung or heart related health problems, or if a patient has other significant diseases or health problems which reduces their normal life expectancy.
Before performing gastric resection surgery, doctors must weigh the risks and benefits carefully for these types of patients.
Total gastrectomy, a surgery to remove the entire stomach, is not recommended when the necessary safe margin (4-6 cm) can be achieved with a lesser surgery called partial gastrectomy (removing just part of the stomach). A partial gastrectomy can be safer and have better long-term effects, especially for older patients, those who are undernourished, or have multiple health problems.
Equipment used for Gastric Resection for Malignancy
Performing a stomach removal surgery, known as a gastrectomy, involves either an open surgery method or a less invasive method called laparoscopic surgery. The choice of method depends on multiple factors such as the complexity of the surgery and the preferences of the surgeon. Both these methods require particular instruments and equipment which are detailed below.
Open Gastrectomy
The instruments and equipment typically required for an open gastrectomy consist of:
– A tool known as a self-retaining table-mounted retractor that helps hold the body open during surgery.
– Various surgical instruments, including different types of scalpels or surgical knives, forceps which resemble tweezers, retractors to hold tissues, scissors, and clamps.
– An electrocautery device, which uses heat to stop blood flow or to remove or cut tissues.
– Threads, also known as sutures, used to stitch wounds.
– Staplers designed for surgical procedures.
– Sterile drapes, gowns, and gloves for hygiene and to prevent infection.
Laparoscopic Gastrectomy
In case of a laparoscopic gastrectomy, the required instruments and equipment might include:
– Laparoscopic instruments such as trocars which act as entry points, graspers to hold tissues, scissors, and retractors.
– Laparoscopes, which include a camera and light source allowing the surgeon to view inside the body during the procedure.
– Monitors to display the images sent by the laparoscope.
– A system for inflating the abdomen with gas to create a working space for surgery.
– A CO2 absorption system to eliminate the gas from the body after the procedure.
– Devices specifically designed for laparoscopic suturing and stapling.
– A vessel sealing device to stop bleeding vessels.
– An electrocautery device for the same purposes as in open surgery.
– Sterile drapes, gowns, and gloves to maintain surgical sterility.
Who is needed to perform Gastric Resection for Malignancy?
The doctor performing a procedure to remove part of the stomach should have sufficient knowledge in surgeries related to the upper part of the abdomen and cancer surgeries. Apart from this skilled surgeon, the team should also include a surgical assistant (a trained professional who helps the surgeon during the operation), an anesthesiologist (a doctor who makes you sleep during the surgery), a surgical technician (a professional trained to assist in surgical procedures), and a circulating nurse (a nurse who helps in the operating room). This highly trained team works together to make sure your surgery goes safely and smoothly.
Preparing for Gastric Resection for Malignancy
Many cases of stomach cancer are not discovered until they are in the late stages. Symptoms of this disease might include weight loss, fatigue, loss of appetite, feeling full too soon after eating, stomach discomfort, blockage of the path from the stomach to the intestine, or not getting enough nutrients from food.
Doctors use various tests to identify who may need surgery to remove part of the stomach, and who might benefit from other treatments. They will often do blood tests to check your overall health. They will also measure levels of certain proteins in your blood that can indicate how well you are eating and metabolizing your food. This helps doctors plan your treatment and understand how well your body might recover.
Doctors begin by looking at your stomach using a special device called an esophagogastroduodenoscopy (EGD) if stomach cancer is suspected. The EGD helps the doctor see the tumor, take a sample of it, and determine its exact location and size.
Further tests to understand the extent of the cancer include an endoscopic ultrasound, which uses sound waves to see how deeply the tumor extends into the stomach wall and check if the cancer has spread to the lymph nodes. A computed tomography (CT) scan of your chest, stomach, and pelvis is also recommended to find out if the cancer has spread further inside your body.
In addition, a special kind of scan called a positron emission tomography (PET) scan is sometimes used to give more information about the cancer staging.
A team of healthcare providers works together to decide if surgery can be done to remove the tumor and to consider chemotherapy or radiation before the surgery. This team will also look at other health conditions you might have to make sure you can safely have the operation. They will also find and control anything that might increase your risk of complications during surgery. For example, it’s known that people who quit smoking before stomach surgery have better results.
How is Gastric Resection for Malignancy performed
Gastric resection, or the removal of part of the stomach, is a procedure that can be performed to treat various conditions, including stomach cancer. Before the procedure, you are given antibiotics and a tube is inserted through your nose and into your stomach to decompress it, or relieve any pressure or gas.
The surgery can be done using several different methods. Firstly, it can be an open procedure, where a large cut is made on your stomach. On the other hand, it can be a minimally invasive surgery, which utilizes special instruments inserted through small cuts, like laparoscopic surgery, or surgery assisted by a robot. Studies have shown that the minimally invasive approaches are just as successful at treating the disease as open surgeries. Furthermore, they also have fewer complications during and after surgery, and patients tend to recover faster and stay in the hospital for a shorter period of time.
Before getting into the main part of the surgery, your surgeon conducts a diagnostic laparoscopy. In this procedure, a small camera is inserted into your belly to look for, and rule out, the presence of hidden cancerous growths in your liver or in the lining of your abdominal cavity. They can then proceed on with the gastric resection.
One technique used in certain cases is called endoscopic submucosal dissection, or ESD. In this method, the area to be removed is marked and then lifted from the deeper layer of muscle. A specialized knife is used to carefully remove the area layer by layer, and the removed tissue is then checked to ensure that all of the affected area has been removed.
Another method is called a total gastrectomy, where the entire stomach is removed. Depending on the location of your tumor, the surgeon makes a cut along the middle of your belly or from the left side of your chest down to your belly. The surgeon then carefully checks for any other cancerous growths, and if none are found, the surgery can continue. After the stomach is removed, the remaining parts of the digestive system are connected back together.
No matter what method is used, your surgeon will choose the best option for your unique situation. Your healthcare team will monitor you for any complications and help manage any discomfort or side effects you might have. The ultimate goal of this surgery is to remove the disease and help you regain your health.
Possible Complications of Gastric Resection for Malignancy
People who are considered high-risk, such as those who use tobacco or are undernourished before the surgery, are more likely to have problems after stomach surgery. This could include bleeding or accidental injury to other body parts during the surgery, such as the spleen.
Despite recent improvements in medical techniques and better post-surgery care, complications can still happen. They could slow down the patient’s recovery, delay additional necessary treatments, and even affect the quality of life. These complications can also affect how long a patient would survive without the disease returning.
Problems related to reduce stomach surgery generally vary in severity and could range from nutritional deficiencies to severe food intolerance, also known as dumping syndrome. Some of these problems can show up days or weeks after the surgery, while others can show up much later.
Early complications could include rupture near the site where the intestine was reconnected, blockages in the bowels, infection at the surgical site, and inside the belly.
Late complications or problems that show up six weeks or more after the surgery could include:
* Bile reflux gastritis: This happens when bile flows into the remaining part of the stomach causing symptoms like upper belly pain, nausea with vomiting, and pain that’s sometimes related to meals. A scan or an endoscopy procedure can usually diagnose this, and it is generally treated surgically.
* Dumping syndrome: This condition is caused by food moving too quickly from the stomach to the small intestine. Symptoms may include abdominal pain, diarrhea, bloating, nausea, flushing, rapid heartbeat, and even fainting. Treatment usually involves changes in diet, medication, or additional surgeries in severe cases.
* Afferent and efferent loop syndrome: These problems can happen after certain types of stomach surgery. Symptoms usually include post-meal pain and cramping followed by vomiting. It’s important to diagnose and treat these problems early to avoid further complications.
* Internal hernia or Peterson hernia: This happens when part of the intestine pushes through a surgical site. It is a known cause of acute abdominal pain in patients who had stomach surgery.
* Other complications can include narrowing at the site where the intestine was reconnected, malnutrition and nutritional deficiencies, stomach ulcers near the surgical site, and return of the cancer.
What Else Should I Know About Gastric Resection for Malignancy?
Stomach surgery for cancer is extremely important because it’s a key treatment for stomach cancer, which is one of the leading causes of death from cancer around the world. The aim of the surgery is to completely remove the cancer and any affected lymph nodes. This could potentially cure the disease if found early and can improve chances of survival in cases where the disease is more advanced. Furthermore, the surgery is critical in reducing symptoms like blockage in the stomach, bleeding, and pain, which can greatly improve the quality of life for the patient.
There have been improvements in surgical techniques, like minimally invasive surgeries using laparoscopy and robotics, which have decreased the risks associated with stomach surgery. This highlights its importance as a treatment option that can cure or ease symptoms in stomach cancer cases. Detecting the disease early, carefully choosing the right patients for surgery, and collaboration among a team of doctors are all important for the success of stomach surgery in treating stomach cancer.
