Can you live without a stomach?

Yes. After total gastrectomy the esophagus is joined directly to the small bowel, and digestion continues further down. You need to eat often and in small portions, receive vitamin B12 for life and have regular blood tests. Many patients return to their usual life and work, although recovery differs from person to person.

Why is chemotherapy given before surgery rather than after?

Chemotherapy before surgery shrinks the tumor, increases the chance of removing it with clear margins and acts on micrometastases that CT cannot show. Some cycles are given after surgery. This sequence is the international standard for operable tumors that have grown into the muscle layer or beyond or involve lymph nodes.

Can early cancer be removed without an incision?

Yes, if the tumor is confined to the mucosa and meets low-risk histologic criteria. It is removed endoscopically during an upper endoscopy, and the stomach is preserved. Suitability is assessed by expert endoscopy, tumor size and biopsy, and confirmed by pathology of the removed specimen.

Should my relatives be tested?

First-degree relatives should be tested for Helicobacter pylori and have an upper endoscopy if indicated. If stomach cancer occurred in several family members or at a young age, genetic counseling is recommended.

Can the operation be done laparoscopically?

Yes, when the tumor’s location and the extent of resection allow. Laparoscopic gastrectomy includes the same extent of lymphadenectomy as open surgery, and recovery is usually faster. The final choice of approach is made after the work-up.

Stomach cancer: work-up, gastrectomy and D2 lymphadenectomy

Stomach cancer gives no specific symptoms for a long time, so it is often found only after the tumor has grown through the stomach wall. Even then, curative treatment remains possible: for most operable tumors the current standard is chemotherapy before surgery, removal of part or all of the stomach with its lymph nodes, and chemotherapy afterward. Early cancer confined to the mucosa can sometimes be removed endoscopically, preserving the stomach. The choice of path depends on the exact stage, so everything starts with a proper work-up.

Kateryna Valikhnovska, MD, surgical oncologist, during a laparoscopic operation — The laparoscopic stage of an operation: the lights in the operating room are dimmed because the surgeon works from the camera image on the monitor.

Why stomach cancer develops

The main risk factor is Helicobacter pylori infection: long-standing inflammation of the mucosa gradually progresses to atrophic gastritis and intestinal metaplasia, on which cancer can develop. That is why the infection is treated once found, and people with atrophy or metaplasia are advised to have regular endoscopy. Smoking, a diet high in salted and smoked foods, alcohol, and previous stomach surgery also raise the risk.

A small share of cases is hereditary: diffuse gastric cancer with a CDH1 mutation, Lynch syndrome, familial adenomatous polyposis. Stomach cancer in several relatives or at a young age points to heredity — in that case genetic counseling for the patient and family is advisable.

Are there symptoms

In the early stages there are usually no symptoms, and the first complaints resemble ordinary gastritis: heaviness after meals, early satiety, heartburn, loss of appetite. Warning signs are unexplained weight loss, anemia, black tarry stools, vomiting after meals, and difficulty swallowing if the tumor lies near the entrance to the stomach.

These signs do not prove cancer, but they are a reason to have an upper endoscopy rather than treat “gastritis” blindly for months.

Examinations needed

Upper endoscopy with multiple biopsies — confirms the diagnosis and shows exactly where the tumor lies relative to the entrance and outlet of the stomach.
Pathology report with biomarkers: tumor type, HER2, microsatellite instability (MSI/dMMR), PD-L1, Claudin 18.2. They determine which drugs may be effective.
Contrast-enhanced CT of the chest, abdomen and pelvis — to assess spread to lymph nodes, liver, lungs and peritoneum.
Endoscopic ultrasound — in uncertain cases, to clarify the depth of invasion; selection for endoscopic removal relies mainly on expert endoscopy.
Staging laparoscopy with peritoneal washings — before curative treatment of tumors that have grown into the muscle layer or beyond: it finds small peritoneal deposits that CT does not show.
PET-CT — when indicated, if CT leaves doubts.
Blood tests and assessment of nutritional status, heart and lungs — before major surgery.

When surgery is possible

Early cancer confined to the mucosa — small, non-ulcerated, with no signs of lymph node involvement and with low-risk histologic features — is removed endoscopically by endoscopic submucosal dissection (ESD). The stomach is preserved. If the specimen shows higher-risk features, surgery is needed.

When the tumor has grown into the muscle layer or beyond or lymph nodes are involved, but there are no distant metastases, the standard is perioperative treatment: several cycles of chemotherapy before surgery, gastrectomy with lymphadenectomy, and completion of chemotherapy afterward. Chemotherapy before surgery shrinks the tumor and destroys micrometastases that imaging cannot show. In recent years, adding immunotherapy has been discussed for some patients — the medical oncologist decides this. Early-stage tumors with no signs of lymph node involvement are usually operated on straight away.

If surgery is not possible now

With distant metastases or peritoneal spread, drug therapy becomes the basis of treatment, and with poor general condition — supportive care. It is selected by biomarkers: an anti-HER2 targeted drug is added for HER2-positive tumors, an anti-Claudin 18.2 drug for Claudin 18.2-positive tumors, and immunotherapy for high PD-L1 or MSI. If the tumor narrows the gastric outlet or bleeds, passage is restored with a stent or a bypass anastomosis, and bleeding is stopped endoscopically or with radiotherapy.

Rarely, in carefully selected patients with a good response to treatment, the MDT discusses the possibility of surgery; this is not a standard path.

How the operation is performed

The extent depends on the tumor’s location and histologic type. For tumors of the lower stomach, a subtotal (distal) gastrectomy is performed — most of the stomach is removed and the upper part is kept. When a subtotal resection cannot remove the tumor with an adequate margin — most often for tumors of the upper and middle third and diffuse-type cancer that spreads through the wall unseen — the whole stomach is removed — total gastrectomy. If there is doubt about clear margins, they are checked by frozen-section analysis during surgery.

An essential part of the radical operation is D2 lymphadenectomy: 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 gastric remnant to the small bowel; after total gastrectomy, usually with a Roux-en-Y reconstruction.

When the tumor’s location and the extent of resection allow, the operation is performed laparoscopically, through several small incisions.

Chemotherapy before surgery is not a delay in treatment but part of it. It offers a chance to remove the tumor completely and to destroy what CT cannot show.

Kateryna Valikhnovska, MD, surgical oncologist

Recovery after surgery

Care follows the enhanced recovery after surgery (ERAS) protocol: early mobilization, early feeding, controlled pain relief. Drinking is allowed early, and food is introduced gradually.

Without a stomach or with a gastric remnant, patients 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 by adjusting the diet. After total gastrectomy vitamin B12 is no longer absorbed from food, so it is 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.

Follow-up

After treatment, well-being, weight, nutrition and blood tests are checked regularly; CT is done on a schedule set by the doctor, and sooner if new complaints appear. After endoscopic removal of early cancer, surveillance endoscopies are mandatory, because a new tumor may develop in the remaining mucosa.

What to bring to the consultation

the endoscopy report describing the tumor’s location, with images if possible;
the pathology report and biomarker results (HER2, MSI/MMR, PD-L1, Claudin 18.2), if already available;
tissue blocks and slides — for review by another laboratory;
CT discs and reports, endoscopic ultrasound and PET-CT results, if performed;
complete blood count and chemistry panel, discharge summaries from previous treatment.

If some materials are missing, that is no reason to postpone the consultation: some examinations can be done on site.

The consultation is free of charge. How it goes and how long it takes is described on the page “Oncologist Consultation”.