Stomach Cancer Surgery: Information & Specialists in Stomach Cancer Surgery

Stomach cancer is one of the most common cancers in Germany. Among men, stomach cancer ranks sixth, and among women, fifth, in terms of new cancer cases each year. In terms of deaths, it is the fourth leading cause of cancer-related deaths for both men and women.

There are approximately 18,500 new cases per year in Germany. This is roughly half the number of new colorectal cancer cases diagnosed each year.

The median age at diagnosis is 68 for men and 74 for women.

Surgical removal of the tumor is the most important component of stomach cancer treatment. Stomach tumors cannot be cured by chemotherapy or radiation therapy. Therefore, stomach cancer surgery is the only chance for a complete cure.

As with other cancer surgeries, two different methods are available:

• open surgery and
• minimally invasive stomach cancer surgery

Open Gastric Cancer Surgery

The traditional method, involving a large incision in the upper abdomen (“open surgery”), has been available for many years. In this procedure, the surgeon opens the abdominal cavity and operates directly on the tumor using his hands and various instruments.

Open stomach cancer surgery allows the surgeon to get a clear view of the area and palpate the exact extent of the tumor.

Minimally Invasive Stomach Cancer Surgery

With the newer minimally invasive surgical technique, also known as laparoscopy, only a few very small incisions are required. 

Through these incisions, doctors insert a camera and tiny instruments into the abdomen. The surgeon views the inside of the abdomen in real time on a monitor and thus operates without a direct view.

This minimally invasive procedure requires specialized experience on the part of the surgeon. It is more expensive than open stomach cancer surgery due to the use of various single-use instruments.

In terms of intraoperative complications and blood loss, there is no difference between the two techniques.

Laparoscopic stomach cancer surgery generally takes slightly longer than open stomach cancer surgery. On the other hand, it requires fewer staff members.

Recovery after laparoscopic surgery is slightly faster than after open surgery due to less pain. Likewise, the cosmetic outcome of laparoscopic surgery is superior to that of open surgery.

The incidence of adhesions or incisional hernias is lower after laparoscopic surgery. In terms of healing and the occurrence of postoperative complications, both surgical techniques are comparable.

In Germany, very few stomach cancer surgeries are performed using minimally invasive techniques (2.5%). Few centers have extensive experience with this specific surgical technique.

Whether minimally invasive or open, curative (healing) stomach cancer surgery involves the removal of the stomach. 

In some cases, a partial removal is sufficient. In such cases, surgeons remove a large portion of the stomach along with the tumor-affected section and the lymphatic drainage area in a single piece (en-bloc resection).

Gastrectomy with D2 Lymphadenectomy

For gastric carcinomas, the standard procedure is the removal of the entire stomach along with the lymph nodes of the first and second compartments. It does not matter whether the gastric cancer surgery is performed open or laparoscopically.

In cases of large tumors, removal of adjacent organs such as:

• the spleen
• the transverse colon, or even
• portions of the diaphragm
• may be necessary to ensure complete tumor removal.

After removing the stomach, doctors must restore the passage of food. Various procedures are available for this purpose, with or without the creation of a replacement stomach. These procedures produce similar outcomes over time.

The most common method is reconstruction via a Roux-Y jejunoesophagostomy. 

In this procedure, special care must be taken to ensure that the distance between the upper and lower anastomoses is between 40 and 60 cm.

Partial gastrectomy with D2 lymphadenectomy

In cases where the tumor is located at the gastric outlet, a 2/3 or 4/5 gastrectomy is possible when appropriate. In such cases, the restoration of the digestive tract is performed using the Roux-Y procedure.

Palliative Surgery

It is not always possible to completely remove the gastric tumor. In such cases, surgeons can create a direct connection between the stomach and the upper small intestine to restore the ability to ingest food.

As with any surgery, this procedure carries risks and dangers. Pre-existing heart or lung conditions can increase the surgical risk.

In such cases, it is important to assess in advance which measures are available to reduce the surgical risk.

There is no alternative to stomach cancer surgery. Therefore, doctors must determine whether it is possible to limit the extent of the procedure while still achieving complete tumor removal.

Complications may also arise that could endanger the patient’s health and prolong the hospital stay.

The following complications may occur after stomach cancer surgery:

Bleeding: Thanks to modern vascular sealing techniques, the risk of significant postoperative bleeding is very low at 1%. The main risk of postoperative bleeding therefore occurs within the first 24 hours after stomach cancer surgery.

Anastomotic leakage: A leak in the suture between two ends of the intestine. In the case of stomach cancer surgery, this can also occur between the esophagus and the intestine or between the residual stomach and the intestine. The risk of this persists until the 7th postoperative day.

This is usually caused by reduced blood flow in the area of the new connection (anastomosis).

There is an increased risk in the presence of comorbidities such as:

• Atherosclerosis
• Diabetes mellitus
• Tobacco use and
• cortisone therapy

In experienced clinics, the rate is less than 5%.

Left: Healthy blood vessels. Right: Blood vessels with atherosclerosis. Atherosclerosis carries a higher risk of complications © Axel Kock | AdobeStock

Wound infections: Wound infections occur in up to 2% of patients following open gastric cancer surgery. These are usually harmless but can prolong the hospital stay and later lead to an incisional hernia.

Pain: Pain following stomach cancer surgery can vary greatly from patient to patient. It also depends on the extent of trauma to the abdominal wall (open or minimally invasive surgery).

The goal is to keep the patient pain-free. This allows for faster mobilization (physical and respiratory therapy). This, in turn, helps reduce the rate of general complications such as pneumonia and thrombosis.

A special form of pain medication administration via a catheter placed near the spinal cord (PDK) can be very helpful in this regard.

Stomach cancer surgery can present challenges for patients in the immediate postoperative period. These challenges primarily concern nutrition. Due to the shortening or absence of the gastric outlet, chyme is transported too quickly into the small intestine. As a result, the body cannot fully absorb the nutrients.

Especially after a total gastrectomy, patients require supplementation with various vitamins and trace elements.

Diarrhea caused by impaired fat digestion can be alleviated with fat-digesting enzymes. Patients can best counteract the weight loss that almost always occurs after stomach cancer surgery by following a diet rich in carbohydrates and protein.

The rapid passage of chyme into the small intestine can also lead to what is known as dumping syndrome.

This leads, either immediately or after a delay of several hours, to:

• Circulatory problems
• Nausea
• Sweating
• Heart palpitations
• Dizziness and
• Low blood pressure

The cause lies in the strain on the intestines and the resulting metabolic disturbances. The best way to address these problems is to spread your food intake over six to ten smaller meals. 

Patients should also avoid drinking immediately before or after meals. A special diet is not necessary.

Because the stomach or part of it has been removed, the pylorus and the lower esophageal sphincter are missing. This can sometimes lead to the reflux of food particles and digestive secretions into the esophagus.

These symptoms can be reduced by eating while sitting upright. The patient should also avoid eating anything for a while before going to bed.

Otherwise, there is a risk that, while lying down, stomach contents may repeatedly enter the lungs and lead to pneumonia.

As with other types of cancer, follow-up care after stomach cancer surgery follows a precisely defined protocol. 

It consists of regular clinical examinations, including:

• tumor marker testing
• Abdominal ultrasound examinations
• Chest X-rays
• CT scans of the abdomen, and
• Regular endoscopic examinations

With timely diagnosis and surgery, a cure is possible depending on the tumor stage.

The 5-year survival rate is 27% for men and 28% for women. Stomach cancer results in an average loss of life expectancy of 8 years for men and 9 years for women.