Stomach Cancer Surgery

When surgery is possible

Surgery is recommended when there are no distant metastases and the tumor can be removed completely together with the lymph nodes. The path is chosen based on the exact stage:

• early cancer limited to the mucosa — small, non-ulcerated, with no signs of lymph node involvement and with low-risk histologic criteria — is removed endoscopically by endoscopic submucosal dissection (ESD). The stomach is preserved. If the removed specimen shows higher-risk features, surgery is needed;
• early-stage tumors with no signs of lymph node involvement are usually operated on right away;
• when the tumor has grown into the muscle layer or deeper, or lymph nodes are involved, the standard is perioperative treatment: several cycles of chemotherapy before surgery, gastrectomy with lymphadenectomy, and completion of chemotherapy after it.

Chemotherapy before surgery is not a delay of treatment but part of it: it shrinks the tumor and destroys micrometastases that are not visible on tests. In recent years adding immunotherapy has been discussed for some patients — this is decided by the medical oncologist.

Before treatment the doctor decides which tests are needed. Depending on the situation, they include:

• upper endoscopy with multiple biopsies — confirms the diagnosis and shows the exact position of the tumor relative to the entrance and exit of the stomach;
• a histopathology report with biomarkers — HER2, microsatellite instability (MSI/dMMR), PD-L1, Claudin 18.2: they determine which drugs may be effective;
• CT of the chest, abdomen and pelvis with contrast — to assess spread to lymph nodes, liver, lungs and peritoneum;
• diagnostic laparoscopy with peritoneal washings — before curative treatment of tumors that have grown into the muscle layer or deeper: it finds small peritoneal deposits that are not visible on CT;
• endoscopic ultrasound and PET-CT — when indicated, if other tests leave doubt.

The disease itself, its symptoms and tests are described on the page “Stomach Cancer”.

If surgery is not possible right now

With distant metastases or peritoneal spread, drug therapy becomes the basis of treatment, and when general condition is poor, supportive care. Drugs are chosen by biomarkers: for a HER2-positive tumor a targeted anti-HER2 drug is added, for a Claudin 18.2-positive tumor an anti-Claudin 18.2 drug, and for high PD-L1 or MSI, immunotherapy.

If the tumor narrows the stomach outlet or bleeds, passage is restored with a stent or a bypass anastomosis, and bleeding is stopped endoscopically or with radiation therapy. Rarely, in carefully selected patients with a good response to treatment, the tumor board discusses the possibility of surgery; this is not the standard path.

How the operation is performed

The extent depends on the tumor location and its histologic type. For tumors of the lower part of the stomach, a subtotal (distal) gastrectomy is performed — most of the stomach is removed and the upper part is left. When a subtotal resection does not allow the tumor to be removed with an adequate margin — most often with tumors of the upper and middle third and the diffuse type of cancer, which spreads unnoticed along the wall — the whole stomach is removed: this is a total gastrectomy. If there is doubt about clear margins, they are checked by frozen-section histology during the operation.

A mandatory part of a curative operation is lymphadenectomy, with D2 as the standard extent: removal of the lymph nodes around the stomach and along its arteries. At least 16 lymph nodes are examined for accurate staging. Continuity is restored by joining the esophagus or the stomach remnant to the small bowel; after a total gastrectomy, usually with a Roux-en-Y reconstruction.

When the tumor location and extent of resection allow it, the operation is performed laparoscopically — through a few small incisions, with the same extent of lymphadenectomy as open surgery. The final choice of approach is made after the workup. More about this approach is on the page “Laparoscopic Surgery”.

Hospital stay, recovery and eating

Recovery follows the enhanced recovery (ERAS) protocol: early mobilization, early eating, controlled pain relief. Drinking is allowed early, and food is introduced gradually. The length of the hospital stay depends on the extent of surgery and the approach.

Without a stomach or with a stomach remnant, people eat often and in small portions, 5–6 times a day. Dumping syndrome may occur — weakness, palpitations and sweating after sweet or large meals; it is managed with eating habits. After a total gastrectomy vitamin B12 is not absorbed from food, so it has to be given for life; iron, calcium and vitamin D levels are also monitored. Weight usually drops in the first months, so a dietitian consultation is helpful.

If treatment started with chemotherapy, it is usually completed after surgery once recovery allows; the regimen is set by the medical oncologist. After that, well-being, weight, nutrition and blood tests are assessed regularly, and CT is done on a schedule set by the doctor and sooner if new symptoms appear. After endoscopic removal of early cancer, follow-up endoscopies are mandatory. If stomach cancer has occurred in several relatives or at a young age, genetic counseling is recommended.

Risks and complications

Risks are what patients ask about least often, although they are the most important thing to discuss before surgery. The main ones include:

• anastomotic leak — when the join between the esophagus or stomach remnant and the bowel does not heal;
• duodenal stump leak and, after lymphadenectomy, pancreatic fistula;
• bleeding during or after surgery;
• infection and general surgical complications, including blood clots;
• effects on eating — dumping syndrome, weight loss, vitamin B12 and iron deficiency; they are managed with eating habits, vitamin B12 and iron supplements, and monitoring of test results.

The likelihood of each depends on the extent of surgery, the approach and general condition. I will explain the risks in your particular case at the consultation.

What the cost depends on

The cost depends on the extent of surgery — subtotal or total gastrectomy, the approach, the number of days in the hospital and the tests. The exact amount is named once the treatment plan has been defined. The payment can be split into parts — installments are available. The in-person consultation is free. More details are on the page “Cost of Surgery: What It Depends On”.

What documents are needed and how to book

• the upper endoscopy report describing the tumor location, with photos if possible;
• the histopathology report and biomarker results (HER2, MSI/dMMR, PD-L1, Claudin 18.2), if already available;
• tissue blocks and slides — for review in another laboratory;
• CT discs and reports, endoscopic ultrasound and PET-CT results, if performed;
• complete blood count and blood chemistry, records of previous treatment.

Book a consultation by phone or through the form. If you are from another city, send the documents in advance — how to do this is described on the page “Online Oncologist Consultation”.