Stomach Surgery

The stomach can get affected by a variety of problems, the majority of those are cancers of the stomach and ulcer disease. Chronic gastritis is also a disease caused by bacteria called Helicobacter Pylori which predisposes the stomach to ulcers and also to cancers.

Adenocarcinoma of the stomach is a common cancer worldwide but is a rare disease in Australia; this cancer arises from the innermost  layer of the stomach also called the mucosa. Other forms of tumours can also arise such as the Gastrointestinal Stromal tumour that arises from the intermediate layer of connective tissue of the stomach.

Stomach cancer is an aggressive disease that is often diagnosed at advanced stages.

Stomach cancer

 

Stomach cancer is a term used to describe cancer that occurs in the stomach. The most common type of stomach cancer occurs within the mucosa (the inside lining of the stomach) also called adenocarcinoma of the stomach. Stomach cancer may invade deeply into the stomach wall and grow into nearby organs, such as the liver, pancreas, colon, oesophagus and intestine.

Risk Factors for Gastric Cancer

Factors that may increase an individual’s risk of stomach cancer include:

  • Smoked food
  • Salted and pickled foods
  • A diet low in fruits and vegetables
  • Family history of stomach cancer
  • Infection with Helicobacter pylori
  • Chronic inflammation
  • Pernicious anemia
  • Smoking
  • Stomach polyps

Signs and symptoms of stomach cancer:

  • Anemia, due to ongoing blood loss that leads to Iron deficiency
  • Bleeding
  • Excessive fatigue
  • Weight loss
  • Feeling full after eating small amounts of food
  • Heartburn or indigestion
  • Abdominal pain
  • Persistent vomiting

Diagnosis

After detailed history and physical examination, a few tests are required to establish the diagnosis. these will include

  1. Upper GI endoscopy
  2. Biopsies
  3. CT scan of the abdomen
  4. PET scan
  5. Staging laparoscopy
  6. Endoscopic ultrasound in selected early cancers.

When the extent of the disease is discussed the first thing to look at is how far the cancer has gone through the wall of the stomach. This sometimes needs an endoscopic examination with ultrasound. However, with a CT scan we usually will have an idea. Also, to look at the regional lymph nodes around the stomach to see whether the cancer has spread to them or not and a PET scan can be particularly useful for this purpose. It is also important to see if there are lesions or spread to the liver and the lung.

Stomach cancer, particularly the diffuse type of stomach cancer can spread to the peritoneal cavity and one of the indications that it might have spread is the presence of fluid in the peritoneal cavity on a CT scan. Often your Doctor will recommend for you what we call a staging laparoscopy. With a staging laparoscopy your Doctor will look at the inside of your abdominal cavity or what we call the peritoneal cavity which is the sack where all the gastrointestinal tract lies inside your abdomen. Because gastric cancer, particularly the diffuse type, can spread in a very subtle fashion with small spots in the peritoneum this is unusual to be picked up by even the most sophisticated scans available and a direct look is required. Also, your Doctor will take some samples from the peritoneal cavity, either in the form of fluid washout or a biopsy to ensure there is no spread to the peritoneal cavity.

Once the cancer is diagnosed and staging has been made the next step is going to be a definitive treatment of the cancer. People who present with disease that has spread beyond cure, which means that surgery has been ruled out, can benefit from some palliative chemotherapy. However, if the lesion is treatable and removable an important option these days is to start with chemotherapy which usually is run in the form of three cycles of chemotherapy. For that purpose you might need to have a reservoir or a line inserted in your chest in order to administer the chemotherapy which is a relatively minor procedure to have a central venous access. Once you have finished the chemotherapy, prior to surgery re-staging is often performed with at least a CT scan and at certain times a PET scan is required to ensure there is no progress of the disease. If the disease responds or remains stable then you will get exposed to surgery of the stomach. There are two types of stomach surgery. One of them involves removal of part of the stomach along with all of the lymph nodes and another form is total removal of the stomach. The factors they take into consideration is the site of the cancer, i.e. its location and also the appearance of the cancer under the microscope. Regardless of the type of the operation you would have lymph node dissection which involves removal of all of the lymph nodes that drain the stomach and once you recover from the surgery you will undergo a further three courses of chemotherapy.

Risk Factors for Stomach Cancer

Factors that increase your risk for developing cancer of the stomach will include

Diet – a high salt diet and smoked food and also pickled food has been linked to increase incidence of cancer of the stomach. Also foods that have got low fruits and vegetables which means a high fruit and vegetable diet is a protector against stomach cancer.

Family history of stomach cancer can be relevant as a small subset of stomach cancers are inherited and these are called hereditary diffuse gastric cancer.

Infection with the bacteria called helicobacter pylori which is the same bacteria that causes ulcers can also predispose you to cancer.

Pernicious anaemia is a chronic inflammation of the lining of the stomach which is considered to be an auto immune disease that does predispose people to stomach cancer also.

Other factors are smoking and stomach polyps. Stomach polyps usually happen in the context of inherited cancer gene, like people with inherited bowel cancer particularly or breast cancer. That can be a predisposing factor for stomach cancer.

Post Surgery

Once you are discharged from hospital with instructions about eating from the dietitian you will be given an appointment to see your surgeon. Once you see your surgeon you will need to discuss the findings of the operation. This often gets discussed in a a multidisciplinary meeting and will also be discussed with you and a family member, if you wish, prior to discharge. The relevant information about the cancer in particular will need to be discussed and these are the stage of the disease which will determine the long term prognosis. This includes how far the cancer has gone in the wall of the stomach and also whether it has spread to lymph nodes and how many of those lymph nodes were involved. All these details will matter in the long term outcome for cancer of the stomach. Also cancers of the proximal stomach have a worse prognosis than those of the distal stomach as well as the histological type of the cancer.

Call the reception of Mr Abbas for more informationCall the reception of Mr Leong for more information

Surgery

 

Surgical removal of most or all of the stomach with dissection of lymph node tissue around the surrounding structures. The amount of stomach removed depends on the size and location of the tumour and also on the type of histology. Surgery also removes a large number of lymph nodes that drain the stomach to maximize the chance of cure by removing what could be a microscopic spread of the disease.

Chemotherapy

Chemotherapy can supplement surgery to maximize the chance to cure the disease. Chemotherapy is often combined with surgery in the treatment of gastric cancer. The utilization of chemotherapy is selective, and may be used before or after surgery and preferably both in three cycles before and after.

Radiation Therapy

In some patients radiation therapy may also be necessary in the treatment of gastric cancer.

Targeted Therapy

Targeted therapy uses drugs that attack cancer cells on specific levels. The most common targeted therapies used for stomach cancer include:

  • Herceptin: for stomach cancer cells that show over-expression of HER2,
  • Imatinib (Gleevec) used for a form of stomach cancer called gastrointestinal stromal tumor.