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Surgery is often part of the treatment for stomach cancer (gastric cancer), if it can be done.

If the cancer hasn't grown into vital structures or spread to other parts of the body and a person is healthy enough, surgery, along with other treatments, offers the best chance to try to cure the cancer.

When is surgery used for stomach cancer?

Surgery can be done:

To remove the cancer: Surgery may be done to remove the cancer and part or all of the stomach, as well as some nearby lymph nodes and other structures, depending on the location and stage (extent) of the cancer. The surgeon will try to leave behind as much normal stomach as possible. Sometimes other organs will need to be removed as well.

To prevent or relieve symptoms: If the cancer is too advanced to be removed completely, palliative surgery might still be done to help prevent or relieve symptoms. For example, it might help control bleeding from the tumor or prevent the stomach from being blocked by tumor growth. This type of surgery is not expected to cure the cancer.

Surgery to remove the cancer

Different types of surgery can be used to try to remove stomach cancer. The type of operation used depends on what part of the stomach the cancer is in and how far it has grown into nearby areas.

Before surgery, talk to your surgeon about how much of your stomach will need to be removed. Some surgeons try to leave behind as much of the stomach as they can, which might allow you to eat more normally afterward. However, the main goal of surgery is to be sure all the cancer has been removed. The surgeon will try to achieve negative surgical margins, meaning that no cancer cells are seen at the edges of the removed part of the stomach, even when looking at it with a microscope.

Endoscopic resection

Endoscopic mucosal resection (EMR)and endoscopic submucosal dissection (ESD) are procedures that can be used to treat some very early-stage cancers, when the tumor is not thought to have grown deeply into the stomach wall and the chance of spread outside the stomach is very low.

These procedures don’t require a cut in the skin. Instead, the surgeon passes an endoscope (a long, flexible tube with a small video camera on the end) down the throat and into the stomach. Surgical tools can be passed through the endoscope to remove the tumor and some layers of the normal stomach wall below and around it.

ESD goes deeper into the stomach wall than EMR, so it’s more likely to remove the tumor completely. But ESD is also a more complex operation, and not all doctors are trained in it, so it might not be available in some centers.

These operations are not done as often in the United States as they are in some East Asian countries (like Japan) where stomach cancer is more common and more often found at an early stage due to screening. If you’re going to have this kind of procedure, it should be done at a center that does a lot of them.

Subtotal gastrectomy (partial gastrectomy)

In this operation, only part of the stomach is removed. This might be recommended if the cancer is only in the lower part of the stomach (in which case it is known as a distal gastrectomy). It might also be an option if the cancer is only in the upper part of the stomach (in which case it is known as a proximal gastrectomy), although this is done less often.

Part of the stomach is removed, sometimes along with the first part of the small intestine (in a distal gastrectomy). The remaining section of stomach is then reattached to the small intestine, which can be done in different ways.

Some of the omentum (an apron-like layer of fatty tissue that covers the stomach and intestines) is typically removed as well, along with nearby lymph nodes (see below). If cancer has reached the spleen or parts of other nearby organs, these are also removed.

Total gastrectomy

This operation is done if the cancer has spread widely in the stomach. It is also often advised if the cancer is in the upper part of the stomach, near the esophagus.

The surgeon removes the entire stomach, nearby lymph nodes (see below), and the omentum, and may remove the spleen and parts of the esophagus, intestines, pancreas, or other nearby organs if the cancer has reached them. The end of the esophagus is then attached to part of the small intestine, which can be done in different ways.

People who have had their stomach removed can only eat a small amount of food at a time. Because of this, they will need to eat more often.

Surgical approaches to subtotal or total gastrectomy

Most subtotal and total gastrectomies are done through a large incision (cut) in the skin of the abdomen (belly). This is sometimes referred to as an open surgical approach.

In some centers, these operations can be done as a laparoscopic gastrectomy, in which long, thin surgical instruments (including one with a small video camera on the end) are inserted into the abdomen through several small cuts. Some surgeons do these operations using robotic-assisted laparoscopic surgery (sometimes just called robotic surgery). In this technique, the surgeon sits at a control panel and moves very precise robotic arms that have laparoscopic instruments on the ends.

Although the laparoscopic approach (including robotic surgery) often results in a shorter hospital stay, less pain after the operation, and a shorter recovery time (because of the smaller incisions), long-term outcomes seem to be about the same with either approach.

No matter which approach is used, it’s very important that your surgeon is skilled and experienced with the technique.

Lymph node removal

In either a subtotal or total gastrectomy, the nearby lymph nodes are removed. This is known as a lymph node dissection or lymphadenectomy, and it's a very important part of the operation. Many doctors feel that the success of the surgery is directly related to how many lymph nodes the surgeon removes.

In the United States, it is recommended that at least 16 lymph nodes be removed (called a D1 lymphadenectomy) when a gastrectomy is done. Surgeons in some East Asian countries (such as Japan and South Korea) have had very high success rates by removing even more lymph nodes near the cancer (called a D2 lymphadenectomy).

It takes a skilled surgeon who is experienced in stomach cancer surgery to remove as many lymph nodes as possible. Ask your surgeon about their experience in operating on stomach cancer. Studies have shown that the results are better when both the surgeon and the hospital have had extensive experience in treating stomach cancer.

Palliative surgery for unresectable cancer

For people with stomach cancer that can't be removed completely, surgery can often still be used to help control the cancer or to help prevent or relieve symptoms or complications.

Gastric bypass (gastrojejunostomy)

Tumors in the lower part of the stomach may eventually grow large enough to block food from leaving the stomach. For people healthy enough for surgery, one option to help prevent or treat this is to bypass the lower part of the stomach. This is done by attaching part of the small intestine (the jejunum) to the upper part of the stomach, which allows food to leave the stomach through the new connection.

Subtotal gastrectomy

For some people who are healthy enough for surgery, removing the part of the stomach with the tumor can help treat problems such as bleeding, pain, or the tumor blocking the passage of food through the stomach, even if the surgery doesn’t cure the cancer. Because the goal is not to cure the cancer, nearby lymph nodes and parts of other organs usually do not need to be removed.

Feeding tube placement

Some people with stomach cancer aren’t able to eat or drink enough to get adequate nutrition. A minor operation can be done to place a feeding tube through the skin of the abdomen and into the lower part of the stomach (known as a gastrostomy tube or G tube) or into the small intestine (jejunostomy tube or J tube). Liquid nutrition can then be put directly into the tube.

Endoscopy procedures

In some situations, endoscopy procedures can be done to help prevent or relieve symptoms, without the need for more extensive surgery:

Endoscopic tumor ablation: In some cases, such as in people who are not healthy enough for surgery, an endoscope (a long, flexible tube passed down the throat) with a laser on the end can be used to vaporize parts of the tumor. This can be done without surgery to stop bleeding or help relieve blockage.

Stent placement: Another non-surgical option to keep a tumor from blocking the opening at the beginning or end of the stomach is to use an endoscope to place a stent (a hollow metal tube) into the opening. This helps keep it open and allows food to pass through it. For tumors in the upper (proximal) stomach, the stent is placed where the esophagus and stomach meet. For tumors in the lower (distal) part of the stomach, the stent is placed at the junction of the stomach and the small intestine.

Possible complications and side effects of surgery

Surgery for stomach cancer is complex and can have complications and side effects.

During the operation, these can include:

• Bleeding
• Blood clots
• Damage to nearby organs

Rarely, the new connections made between the ends of the stomach, esophagus, and small intestine may leak.

Surgical techniques have improved over time, so only a very small percentage of people die from surgery for stomach cancer. The chance of this happening is higher when the operation is more extensive, such as when other organs are removed, but it is lower in the hands of highly skilled surgeons.

After a total or subtotal gastrectomy, you won’t be allowed to eat or drink anything for at least a few days. This is to give the digestive tract time to heal and to make sure there are no leaks in parts that were connected together during the operation.

Side effects after surgery can include:

• Nausea
• Heartburn
• Abdominal (belly) pain
• Diarrhea, particularly after eating

These side effects result from the fact that once part or all of the stomach is removed, food enters the intestines much more quickly after eating. They might get better over time, but for some people they might not. Your doctor may prescribe medicines to help with them.

Diet and nutrition issues

You might need to make changes in your diet after a partial or total gastrectomy. The biggest change is that you will need to eat smaller, more frequent meals. The amount of stomach removed will affect how much you need to change the way you eat.

Some people might have trouble taking in enough nutrition after surgery for stomach cancer. Further treatment like chemotherapy and radiation after surgery can make this problem worse. To help with this, a tube is sometimes placed into the intestine, either at the time of the surgery or afterward. The other end of this tube, called a jejunostomy tube or J tube, remains outside the skin on the abdomen. Liquid nutrition can be put directly through this tube into the intestine to help prevent or treat malnutrition.

The stomach helps the body absorb some vitamins, so people who have had a subtotal or total gastrectomy might develop vitamin deficiencies. If certain parts of the stomach are removed, doctors routinely prescribe vitamin supplements, some of which can only be injected.