Stomach Cancer Surgery

The stomach is a J-shaped organ that helps in the break-down and digestion of food and processes the nutrients. It is a muscular organ that has many layers to it. Most gastric cancers begin in the innermost layer of the stomach that comes in contact with food.

Gastrectomy is a common choice of treatment for stomach cancer, and it may be partial or total. Partial gastrectomy means removing a part of your stomach and the nearby lymph nodes to test if they contain cancer cells. Total gastrectomy is done when the stomach cancer is in an advanced stage but has not yet spread to any other parts or organs.

The type of surgery chosen depends on several factors such as type, location, size, and stage of the tumour as well as the individual’s age and general health.

Few minimally invasive surgery options, such as laparoscopy or robot-assisted surgery, may also be considered.

Doctors may recommend this surgery if any individual has been diagnosed with stomach cancer or shows the following signs or symptoms that do not improve or get worse over a period of time:

• Weight loss (unexplained)
• Poor appetite or loss of appetite
• Stomach pain
• Discomfort in the abdomen (generally above the navel area)
• Heartburn/indigestion
• A feeling of fullness in the abdomen even after eating a small meal
• Vomiting (with or without blood) Read more: Vomiting blood causes
• Swelling or building up of fluid in the abdomen
• Blood in stool
• Low red blood cells (anaemia)

An individual diagnosed with a stage 0, I, II or III stomach cancer can be treated with surgery and some additional treatments.

Stomach cancer surgery may not be advisable in individuals diagnosed with stage IV gastric cancer in which the cancer cannot be removed by surgery or if the cancer has recurred. In such cases, chemotherapy or targeted therapy is used as palliative therapy that reduces the symptoms and improves the quality of life.

Before the surgery:

• Your doctor will explain the entire procedure to you and shall resolve all your doubts and queries about the procedure. 
• He/she will ask you details of the last time you ate or drank and will carry out some tests to check your fitness and overall health.
• The doctor may also take your medical history and conduct some tests such as blood tests, physical examination, upper endoscopy, ECG, breathing tests (lung function tests), echocardiogram and chest x-ray.
• The dietician will explain how the operation might affect your diet and advise you on managing your diet. 
• The anaesthetist will ensure you are fit and ready for the surgery.

Staging will be carried out to find out if the cancer cells have spread within the stomach or to any other body parts. The information that comes from the staging process determines the stage of the disease.

Staging can be done using the following tests:

• Endoscopic ultrasound: In this test, a thin, tube-like instrument with a light and a lens called an endoscope, is inserted through your mouth or rectum to view the internal tissues or organs. 
• Computed tomography (CT) scan: In this test, a dye will be injected into your veins or you will be asked to swallow it so that the internal organs or tissues can be seen more clearly. A series of detailed pictures of the inside of the body is made by a computer linked to an x-ray machine. 
• Positron emission tomography (PET) scan: PET scan is an imaging procedure to find malignant tumour cells in the body wherein a small quantity of radioactive glucose is injected into a vein. The PET scanner makes a picture of where the glucose is being used inside the body. The malignant tumour cells (abnormal cells) show up brightly in the picture as they are highly active and consume more glucose (sugar) than the normal cells. Sometimes, a PET and CT scan may be done at the same time, which is called a PET-CT scan. This test tells us if the cancer cells have spread to other organs.
• Magnetic resonance imaging (MRI): This test procedure includes radio waves, a magnet and a computer to make a series of detailed images of the areas inside the body. A substance called gadolinium is administered into a vein. It gathers around the cancer cells, due to which they show up brighter on the picture. Read more: MRI scan procedure
• Laparoscopy: Laparoscopy is a surgical procedure to look at the organs inside the abdomen to check for signs of disease. Small cuts are placed on the wall of the abdomen, and a laparoscope (a thin tube with a light and lens used to look at tissues, organs inside the abdomen) is inserted into one of the incisions. Other instruments are also inserted via the same incision or another incision to obtain samples of tissues. The samples are then looked at under a microscope to check for signs of cancer.

An operation for stomach cancer is a major one and the steps of the surgery are as below:

• You shall be asked to get admitted on the morning of your surgery and sign a consent form for the surgery.
• Right before the surgery, you will be asked to remove any jewellery, contact lenses or makeup.
• You will also be given a hospital gown to change into and will be asked to wear a pair of surgical stockings during and after the surgery. Surgical stockings will help prevent blood clots in your legs.
• The nurse will record your pulse, blood pressure and breathing rate. You might be asked to take medicines to relax an hour before going to the operation theatre. 
• You will be first given anaesthesia, to put you in a deep sleep, so that you won’t feel anything during the surgery.

After this, you may undergo surgery via open or laparoscopic (keyhole) method to remove the cancer:

• Open Surgery: For this surgery, a cut will be made on your abdomen and, if needed, the chest. Depending on the location of the cancer, open surgery is of the following types:
  • A sub-total gastrectomy - surgery via a cut in the abdomen that leaves one vertical scar
  • Total gastrectomy - involves one cut to the abdomen to remove the entire stomach, which leaves one upside-down V scar on your abdomen
  • Thoraco-abdominal oesophagal-gastrectomy - involves the removal of stomach and food pipe via a cut in the abdomen and chest which leaves one scar across the chest and one down the middle of the abdomen.
• Keyhole surgery: It is also called minimally invasive surgery or laparoscopic surgery. In this surgery, the surgeon will make four to six small cuts in your abdomen, instead of one big cut. Keyhole surgery makes use of a laparoscope and can remove a part of or the entire stomach.

The following types of surgeries may be performed via the open or keyhole method depending on the stage of the cancer:

• Endoscopic mucosal resection: This type of surgery is used to treat small, early-stage cancer (less than 2 cm) that has not spread beyond the inner wall of the stomach. To conduct this surgery, an endoscope will be inserted into your stomach via your mouth and throat. Saltwater will then be pushed under the tumour to lift it and remove it easily. 
• Limited surgical resection (or wedge resection): Limited surgical resection is used to treat small tumours (less than 3 cm) and to remove the part of the stomach that contains the tumour along with a healthy margin around the cells. This surgery may be performed by the open route or laparoscopy.
• Distal subtotal gastrectomy: It is used for treating tumours located in the lower (distal) part of stomach. In this, the lower part of stomach along with a healthy margin, a part of the duodenum and surrounding lymph nodes are removed. Then the gastrointestinal (GI) tract is rebuilt by joining a part of the small intestine to the remaining upper part of stomach (Roux-en-Y procedure). 
• Proximal gastrectomy: This procedure is used for treating tumours in the upper (proximal) part of the stomach and in the region where the stomach connects with the oesophagus. Here the upper part of the stomach along with a healthy margin, a part or whole of the lower part of the oesophagus and the nearby lymph nodes are removed. Then, the GI tract is rebuilt by pulling the remaining part of stomach to the remaining upper part of oesophagus (gastric pull up).
• Total gastrectomy: Total gastrectomy is used as a treatment for a tumour located in the middle or upper part of the stomach or when cancer has spread throughout the stomach. In this procedure, the entire stomach, the lower part of the oesophagus, the initial (first) part of duodenum, any nearby organs (pancreas, spleen or liver) where cancer has spread and the nearby lymph nodes are removed. Then, the gastrointestinal tract is rebuilt.

After the surgery

When the surgery is completed, you will wake up in the intensive care unit or recovery ward where the nurses will be monitoring you closely. Your doctor will also check on your progress. Most of the time, you will feel drowsy due to the effect of medicines. You will be moved back to your room or ward within a day.

You might have an oxygen mask on and may see a few tubes attached to you when you wake up. These tubes are as follows:

• A wound drain to drain out the excess blood or fluids
• A chest drain that helps your lungs to expand if the stomach and part of the food pipe was removed
• A tube into your bladder to measure the urine you pass
• A small tube into an artery to monitor your blood pressure
• A nasogastric tube through your nose down into the stomach to drain it
• A tube through a vein in your neck, for giving you fluids and blood transfusions

These tubes are drains that prevent fluid from collecting at the surgery site as the body heals. The drains may be removed in 1 to 3 weeks or when the drainage reduces to 30 mL or less for 2 days at a stretch. Once the drains are removed, the drainage sites should be kept dry by placing a gauze dressing over it for the first 48 hours.

You should not eat or drink immediately after the surgery. After 24-48 hours, when you are allowed to drink, you should start with small sips of water. Most people will be able to eat small amounts within a week. Some people may require a feeding tube to help them maintain their nutrition. 

You might get feeds through a tube into your stomach or small bowel (enteral nutrition) or into the bloodstream through a drip into a vein (parenteral nutrition). A feeding tube might be placed if you:

• Cannot absorb nutrients from your gut
• Were severely malnourished before surgery
• Have holes or an abscess in the oesophagus or stomach

The recovery of an individual depends on how much of the stomach is removed by the surgeon. Typically, individuals need to stay in the hospital for around five to eight days. Your wound (or wounds) will have dressings that will be changed and cleaned by the nurse after a few days. The stitches might remain for 10 days and are usually removed before you leave the hospital. However, if your wound is not properly healed or is still healing, you might be allowed to go home with the stitches. 

The stitches will be removed when you visit for a check-up in a couple of days, and the nurse will advise you about the precautions that should be taken for the wound. Here are some things that you need to take care of the surgery

Wound care: A nurse or your doctor may advise you on how to take care of your wound at home. All wounds will go through several stages of healing and you can see those changes over time. You may experience the following as the wound heals:

• Uncommon or unexpected sensations such as numbness, itching or tingling
• A slight pull around the stitches
• A slight hard lumpy feeling as the new tissue grows

Do not pull off any scabs as they act as natural dressing and will wear off automatically. If an infection develops in the wound, as indicated by increased redness of the skin and pus formation, you may need antibiotics to treat the infection. If the wound opens up, you should get it checked and dressed by the healthcare provider.

Diet: Your diet should change after the surgery to suit your stomach. When you are able to feed on your own without the tube, a soft diet will help you cope with chewing/swallowing issues. The following tips can help you with your diet:

• Have small frequent meals and increase your nutritional intake every day so the stomach gradually gets used to it.
• Avoid foods that need you to chew a lot and are hard to swallow, like raw vegetables and nuts.
• Eat more of stews, cereals, milkshakes and moist food.
• You may use a liquidiser to process solid foods.
• Add butter, cream, milk to your diet in order to put on weight.
• Avoid eating or drinking very hot foods. Warm foods and cold foods may be soothing.

If a part of or the entire stomach is removed, then your stomach cannot produce a substance called intrinsic factor that helps you absorb vitamin B12 from the blood. So, you may need vitamin B12 injections every 3 months.

Activities: You will most likely feel tired for a couple of weeks after the surgery. So you start walking slowly around the house and gradually increase the amount of time you walk. You can slowly progress to walking outside after a while. Read more: Benefits of taking walks

When to See the Doctor?

You must visit your doctor immediately if you experience any of the following symptoms:

• Increased pain
• Difficulty in eating or swallowing
• Vomiting
• Weight loss
• Swelling of the abdomen
• A change in the body that worries you

The possible complications or risks of stomach cancer surgery include internal bleeding from the surgery, blood clots, wound infection, chest infection and blockage of the small intestine. Rarely, the new joints made between the ends of the stomach or oesophagus and the small intestine may leak. 

Other side-effects that may develop after recovery are:

• Feeling full early after eating or drinking
• Nausea
• Vomiting
• Heartburn
• Abdominal swelling Read more: Ascites symptoms
• Diarrhoea
• Weight loss

Some of these side-effects get better with time, and your doctor may suggest medicines to help you cope with these effects. You must eat smaller, more frequent meals after this surgery.

Your doctor may suggest follow-up appointments every few months to check on how you are doing and whether you have any side-effects. At times, you may have to do a few tests during the follow-up visits, such as blood tests, X-ray, CT scan, ultrasound scan or endoscopy.

The follow-up visits become less frequent gradually. After the surgery, the first check-up is generally scheduled at three months; then every three months for the first two years, followed by every six to 12 months for the next three years and every year after that.

Disclaimer: The above information is provided purely from an educational point of view and is in no way a substitute for medical advice by a qualified doctor.