Stomach Cancer (Gastric Carcinoma): Surgical Therapy

Notice:

  • Endoscopic submucosal dissection (ESD; see below) is the treatment of choice for early gastric cancer.
  • Staging laparoscopy (abdominal endoscopy for staging) improves treatment decisions in locally advanced gastric carcinoma (especially cT3, cT4) and should be performed before initiation of neoadjuvant chemotherapy (NACT; to reduce tumor mass before surgery).
  • Surgical resection (surgical removal of tumor tissue) represents the only option for curative treatment (cure) [S3 guideline].

Adenocarcinoma of the stomach

Stage Measures
IA IA T1a Endoscopic or surgical resection
IA T1b Surgical resection (surgical partial removal of an organ)
IB-III
  1. Preoperative chemotherapya, thereafter
  2. Surgical resection, thereafter
  3. Postoperative chemotherapy
IV Drug tumor therapy and/or BSC

Legend

  • AAdjuvant chemotherapy or radiochemotherapy if preoperative chemotherapy was not performed.
  • BBest supportive care.

1st order

  • “Early carcinoma” with limitation of the depth of infiltration of the carcinoma to the mucosa (mucosa) (T1m) and submucosa (tissue layer between the mucosa and muscle layer) (T1sm) is treated per curative endoscopic mucosal resection (EMR; surgical removal of the mucosa) or submucosal dissection (Engl. endoscopic submucosal dissection, ESD; en bloc resection of lesions).Intraepithelial neoplasms (precancerous tumor that is a possible or confirmed precancerous lesion) of any size and early gastric carcinomas that meet all four criteria (A-D) should be resected endoscopically en bloc:
    • Size < 2 cm in diameter, non-ulcerated, mucosal carcinoma, intestinal type or histologic grade of differentiation good or moderate (G1/G2).

    Note: The 5-year overall survival and disease-specific 5-year survival in patients with early gastric carcinoma are comparable after laparoscopic and classic gastrectomy; the postoperative outcome favors the laparoscopic approach.

  • “Early carcinoma” (T1a N0 M0), ie. tumor is limited to the mucosa and must not have metastasized (spread) to lymph nodes or other organs/bones, whose tumor is well or moderately differentiated (G1 or G2) and is not > 2 cm (a flat tumor must not be > 1 cm), can be resected (surgically removed) with organ preservation laparoscopically (minimally invasive surgery: Endoscopic subtotal distal resection (partial removal of the lower part of the stomach) or by gastrectomy (complete removal of the stomach). For this, all 4 of the following criteria should be met [guidelines: S3 guideline]: ≤ 2 cm in diameter, non-ulcerated, mucosal carcinoma, intestinal type or histological grade of differentiation good or moderate (G1/G2)Endoscopic submucosal dissection (ESD; en bloc resection of lesions) should be used for resection. If more than one extended criterion is present, oncologic surgical resection should be performed.Risk of recurrence (tumor recurrence): approximately 15%]
  • In locoregionally limited tumor (T 1 b/2) is primarily a surgical therapy: depending on the size and penetration depth of the tumor, a subtotal gastric resection (partial gastric resection; partial gastric removal; often referred to as gastric resection) or a total gastric resection (complete gastric removal = gastrectomy / lymph node removal) may be indicated. This is performed as standard with lymphadenectomy (surgical removal of lymph nodes).
  • Localization of the tumor in the esophagogastric (esophagus-stomach) junction (AEG type II) with infiltration of the lower esophagus [S3 guideline]:
    • Transthoracic subtotal esophagectomy with proximal gastric resection (partial esophagectomy with upper partial gastric resection) according to Ivor Lewis; alternatively, transhiatal extended gastrectomy (complete gastric resection) with distal esophageal resection (lower esophageal partial gastric resection; esophago-gastrectomy (total esophageal and gastric resection) may be required in cases of additional extensive gastric involvement.
  • In advanced tumor stages (T 3 and above), consider the possibility of neoadjuvant (preparatory), perioperative, or adjuvant (adjuvant) chemotherapy for “downstaging” (improving tumor staging, especially with respect to size and infiltration). [probably chemotherapy before or after surgery is only appropriate for young patients (50-69 years)]
  • In advanced tumor stages (from T 3), in tumors that have already grown beyond the stomach wall (T4), or when small amounts of ascites (abdominal fluid) are detected, a laparoscopy (laparoscopy) may be useful to exclude a possible tumor involvement of the liver and peritoneum (abdominal cavity).
  • Note: Patients with resectable gastric carcinoma with microsatellite instability (MSI)-high status have better survival than patients with tumors with low or no MSI (5-year OS 78 vs 59%) 3. The authors avoid the possibility that perioperative chemotherapy may not do the patient any good.

The goal of surgical therapy is complete tumor removal as R0 resection (removal of the tumor in healthy tissue; no tumor tissue is detectable in the resection margin on histopathology). The necessary safety distance is 5 cm in situ for intestinal carcinoma, and 8 cm for diffuse type.Quite crucial in curative therapy of early gastric carcinoma is attention to possible lymph node metastasis.Gastrectomy is a surgical procedure for complete removal of the stomach (total gastric resection). If only part of the stomach is removed, it is called gastric resection or partial gastric resection:After removal of the stomach or part of the stomach, the esophagus (food pipe) is sutured to the remaining part of the stomach or duodenum (duodenum) to allow continued passage of food:Several procedures can be distinguished for different indications:

  • Antrum resection – removal of the last section of the stomach before the transition to the duodenum (duodenum).
  • Billroth I resection – partial removal of the stomach; subsequent anastomosis (connection) between the gastric remnant and the duodenum (duodenum).
  • Billroth II resection – partial removal of the stomach; subsequent anastomosis (connection) between the gastric remnant and the jejunum (empty intestine); the upstream portion of the intestine ends blindly and is connected to the draining jejunum portion
  • Roux-Y resection – reconstruction procedure after gastrectomy; anastomosis (connection) between the gastric remnant and the jejunum (empty intestine); the duodenum (duodenum; physiologically upstream) is also connected to the jejunum (so-called end-to-side anastomosis)
  • Total gastrectomy – total stomach removal.

Complications/consequential diseases

  • Bleeding
  • Infections
  • Wound healing disorders
  • Incisional hernia – abdominal wall hernia in the area of the surgical scar.
  • Suture insufficiency – inability of the suture to adapt the tissues.
  • Dumping syndrome (postgastrectomy syndrome).
  • Anastomotic stenosis – narrowing of the connecting suture.
  • Anastomosis ulcer – formation of ulcers in the area of the connecting suture.
  • Thromboembolism – occlusion of a pulmonary artery by a blood clot.
  • Pneumonia (inflammation of the lungs)
  • Malnutrition (malnutrition)
  • Alkaline reflux esophagitis – esophagitis in which gastric acid and pepsin do not play a role.
  • Iron deficiency anemia – anemia due to iron deficiency.

The surgical risk is less than five percent for gastric resection performed in experienced centers. In case of complications such as bleeding or stenosis (narrowing) in the stomach, it may be necessary to perform a partial gastric resection or gastrectomy (stomach removal), but without a curative (healing) approach. Recurrence

In the case of isolated local recurrence (recurrence of the disease at the same site), another operation may be performed. Further notes

  • One study demonstrated that surgical removal of the primarius (original lump of a malignant metastatic tumor) while leaving the metastases (daughter tumors) in place, unlike perhaps in colon cancer, provides no benefit and is therefore not recommended.