Surgery for Gastric Cancer: What You Need to Know

If not treated, it can grow and spread, but there are effective treatments available. Surgery is often the most critical part of the treatment process. While hearing the word “cancer” can be frightening, it’s important to know that many people with gastric cancer undergo surgery, recover, and continue to live fulfilling lives.

Why Surgery?

Surgery is the cornerstone of treatment for gastric cancer when the disease has not spread to other organs. The goal of surgery is to remove the cancer, along with part or all of the stomach, depending on how much the cancer has spread. Surgeons aim to ensure that no visible clusters of cancer cells are left behind, which gives patients the best chance at long-term survival.

“So in terms of surgical options, we know for certain that removing the cancer really offers the best opportunity to cure or to eradicate the cancer. So more often than not, as many patients who are candidates for surgery, we want to make sure that they get that modality of treatment,” Dr. Olatunji B. Alese, a medical oncologist from Winship Cancer Institute of Emory University, tells SurvivorNet.

For patients whose cancer is at an earlier stage, surgery can often be curative. Even for those with more advanced cancer, surgery may still be an option to help control symptoms and improve quality of life.

“Surgery is more important in gastric cancer than many others. Something called a D2 resection, or lymph node removal, versus D1, massively changes survival,” Dr. Nicholas Hornstein, a medical oncologist at Northwell Cancer Institute in Manhattan, tells SurvivorNet.

Types of Surgery

Lymphadenectomy refers to the removal of lymph nodes during surgery to assess if cancer has spread beyond the stomach.

“As part of that surgery, we always do what we call a lymph node dissection, meaning removal of lymph nodes in the area even if we don’t see any suspicious lymph nodes on what we call clinical staging. Clinical staging means before the removal by the surgeons and evaluation by pathologists under the microscope,” Dr. Sofya Pintova, a gastrointestinal medical oncologist at Mount Sinai Cancer Center in New York City, explains.

The extent of lymph node removal is classified as D1, D2, or D3, and understanding the differences between these options can help patients and their loved ones make informed decisions alongside their medical team.

• D1 Lymphadenectomy: In a D1 lymphadenectomy, the surgeon removes only the lymph nodes immediately surrounding the stomach, known as the perigastric lymph nodes. These are the first nodes cancer is likely to spread to, making this a more conservative approach. This method carries fewer risks, such as complications during or after surgery, and a shorter recovery time, but may not be as comprehensive in catching cancer cells that have spread further.
• D2 Lymphadenectomy: A D2 lymphadenectomy involves removing a broader set of lymph nodes, including both the perigastric nodes and those located farther away, such as around the major blood vessels near the stomach (second-tier nodes). D2 lymphadenectomy is considered the standard in East Asian countries and is increasingly accepted in Western countries, especially in specialized centers with experienced surgeons. This approach can improve survival rates but may come with a higher risk of complications if not performed by skilled professionals.
• D3 Lymphadenectomy: The most extensive form of lymph node removal, D3 lymphadenectomy, takes the procedure even further by removing not only the perigastric and second-tier lymph nodes but also those located in more distant regions, such as the area near the pancreas and along the aorta (third-tier nodes). This approach is less common and is typically reserved for cases of highly advanced or aggressive gastric cancer, where there’s a higher likelihood that the cancer has spread to these more distant nodes. While D3 lymphadenectomy offers the most comprehensive removal of potential cancerous lymph nodes, it also carries the highest risk of complications, including longer recovery times and potential for greater impact on the patient’s quality of life post-surgery.

Total vs. Partial Gastrectomy

When discussing surgery for gastric cancer, one of the main decisions a surgeon makes is whether to perform a total gastrectomy or a partial (subtotal) gastrectomy. This decision depends on the location and stage of the cancer, as well as other individual factors like overall health and patient preferences.

• Total Gastrectomy: In this procedure, the surgeon removes the entire stomach. This is usually necessary when the cancer is more proximal (near the esophagus, the tube that connects your mouth to your stomach). After the stomach is removed, the esophagus is attached directly to the small intestine. While this may sound alarming, it’s important to know that people can live without a stomach. However, you’ll need to adjust how and what you eat. Eating smaller, more frequent meals becomes essential, and your body will need time to adapt to these changes.
• Partial (Subtotal) Gastrectomy: If the cancer is located in the distal part of the stomach (away from the esophagus), and it hasn’t spread extensively, a subtotal gastrectomy may be an option. In this surgery, the part of the stomach containing the tumor is removed, and the remaining part of the stomach is reconnected to the small intestine. Because part of the stomach remains intact, patients undergoing partial gastrectomy typically experience fewer dietary restrictions than those undergoing a total gastrectomy. This type of surgery can be highly effective in removing the cancer while allowing for a somewhat more normal post-surgery eating routine.

While both surgeries aim to remove the cancer, they each come with different challenges and outcomes regarding how the body processes food. Your surgeon will carefully assess the best option for you based on where the cancer is located and other individual health factors.

Open vs. Laparoscopic vs. Robotic Surgery

Another important aspect of gastric cancer surgery is the approach the surgeon takes—open surgery, laparoscopic surgery, or robotic surgery. Each approach has its pros and cons, and understanding these can help you have a more informed discussion with your medical team.

• Open Surgery: This is the traditional approach to surgery, where the surgeon makes a large incision in the abdomen to access the stomach and remove the tumor. While open surgery allows the surgeon a clear view of the cancer and surrounding areas, it often comes with a longer recovery time and more postoperative pain due to the size of the incision. Open surgery may still be necessary for very large tumors.
• Laparoscopic Surgery: Laparoscopic surgery is a minimally invasive approach where the surgeon makes several small incisions rather than one large one. A tiny camera is inserted into one of the incisions to guide the surgery. This approach generally leads to faster recovery times, less postoperative pain, and shorter hospital stays compared to open surgery. However, not all patients are candidates for laparoscopic surgery, especially if the cancer is very advanced or if it involves other nearby organs.
• Robotic Surgery: Robotic surgery is a more advanced form of minimally invasive surgery. Using a robotic system, the surgeon controls instruments with high precision through small incisions, similar to laparoscopic surgery. The robot provides enhanced visualization and dexterity, allowing for more delicate and precise movements. This approach can be particularly beneficial in complex cases where accuracy is essential. Like laparoscopic surgery, robotic surgery typically results in faster recovery times and less pain, but it may not be suitable for every case.

The choice between these surgical approaches depends on several factors, including the size and location of the tumor, the stage of cancer, and your overall health. Minimally invasive techniques like laparoscopic or robotic surgery can offer faster recovery, but they require specialized surgical expertise and aren’t always possible.

What to Expect After Surgery

Recovery from gastric cancer surgery is a journey, and it’s normal to have concerns about what life will be like afterward. The healing process can take time, and patients may experience changes in their eating habits. Most people will need to eat smaller, more frequent meals as their body adjusts to a smaller or absent stomach.

Many patients can live a normal, healthy life after surgery, though it’s essential to attend follow-up appointments and communicate any new symptoms with your healthcare team.

Recovery After Surgery

After surgery, whether it was a partial or total gastrectomy, you will spend three to 10 days in the hospital for close monitoring and care. Your medical team will be there to ensure you recover safely and will help manage pain, prevent infections, and monitor for any complications.

• Pain Management: Post-surgery discomfort is normal, but pain is well-managed with medications and pain killers.
• Tubes and Drains: You may have one or two tubes placed temporarily to assist with your recovery, such as:
  • A nasogastric tube that drains fluid from the stomach to keep it empty while it heals.
  • A nasoenteral tube that allows food to enter your intestines. You will most likely have one of these, if you have a total gastrectomy.
  • Drains near your surgical site to remove any excess fluid.
  • An intravenous (IV) line to deliver fluids and medications while you’re unable to eat or drink.

Dr. Alese says, “Pain in gastric cancer can come from different sources. Sometimes it is due to the tumor, which oftentimes is painful because it’s growing in an area that it shouldn’t. Sometimes the pain is due to the treatments. We work collaboratively with other specialists like palliative or supportive oncologists to come up with the best pain regimen.”

One of the most significant changes after gastric cancer surgery is adapting to a new eating routine. Whether part or all of your stomach was removed, the way your body digests food will change.

Your medical team, including a dietitian, will help guide you through this transition, which may include:

• Smaller, More Frequent Meals: Without a full stomach to hold food, you will likely need to eat smaller, more frequent meals throughout the day. This helps your body absorb the nutrients it needs without overwhelming your digestive system.
• Food Sensitivities: Some foods may be harder to digest or cause discomfort after surgery. Over time, you’ll learn which foods work best for you. Many people need to avoid very sugary or fatty foods as these can cause discomfort or diarrhea.
• Dumping Syndrome: Some patients experience a condition called dumping syndrome, where food moves too quickly through the digestive system, causing nausea, diarrhea, or dizziness after eating. This can be managed by adjusting your diet, eating slowly, and avoiding high-sugar foods.

While these changes may feel overwhelming at first, many patients gradually adjust and find a new normal with the help of their healthcare team. It’s important to stay patient and know that this is part of the recovery process.

Physical Recovery at Home

Once you are home, your recovery will continue. Here’s what to expect and how to cope:

• Wound Care: You will need to take care of your surgical incision site. Your healthcare team will give you detailed instructions on how to keep it clean to prevent infection. It’s important to follow these guidelines closely.
• Energy Levels: Fatigue is common after major surgery. You may feel tired for weeks or even months as your body heals. Rest is essential, but light activity, such as walking, can help speed up recovery and reduce the risk of complications like blood clots.
• Emotional Well-being: Surgery for gastric cancer is not just physically demanding—it can be emotionally overwhelming too. It’s completely normal to feel a range of emotions, from relief to anxiety, sadness, or even depression. Don’t hesitate to talk to a counselor or therapist, or join a support group. You’re not alone, and emotional support is just as important as physical healing.

While gastric cancer is a serious diagnosis, it’s important to remember that treatments continue to improve, and more patients are surviving and thriving after surgery. Research into gastric cancer is advancing, with new therapies and surgical techniques making a real difference. No matter where you or your loved one are in the journey, there is hope.

Questions to Ask Your Doctor

• What type of surgery will I need, and why?
• What are the risks and potential complications of this surgery?
• What can I expect during my recovery, and how long will it take?
• Will I need additional treatments after surgery, such as chemotherapy or radiation?
• How will my diet and eating habits change after surgery?

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