SURGICAL MANAGEMENT The operation you have to remove your stomach cancer will depend on which part of the

stomach the cancer is in. You may have part or all of your stomach removed. If your cancer has spread to another part of your body, you are unlikely to have these operations as they will not cure your cancer. You may have an operation to bypass or remove part of the tumour if it blocks your food pipe (oesophagus) or stomach. But these days you are more likely to have a thin flexible tube called a stent put into the area of the blockage. The stent allows food to pass through. You may also have chemotherapy to shrink the cancer. There is information about this in the section on surgery to relieve symptoms of stomach cancer. There is information about research into new ways of doing surgery in the stomach cancer research section. Palliative surgical treatment The best palliation in GC whenever possible is still surgical resection. In fact, morbidity and mortality of palliative surgery without resection (laparotomy alone or by-pass procedures) is extremely high and should be avoided. Perhaps a better pre-operative evaluation by CT scan (heliscan) and/or laparoscopic staging indicated in selected patients could decrease the number of explanatory laparotomy in unresectable GC (34). Although, 25% of the patients with diagnosed GC can benefit from palliative procedures (3). There are two different types of the palliative treatment of GC: resection of the tumor and surgical by-pass procedures without resection. Actual pre-operative investigations can not always predict the type of operative procedure as exactly as during operative exploration. Laparoscopic staging could be indicated in these conditions (34). Mostly, in many cases, the possibility of tumoral resection appears to surgeons as a perioperative finding, and per-operative manual exploration may find hepatic metastasis, wide or localized peritoneal implants. in these conditions, palliative surgery depends on local anatomy and preoperative clinical symptoms. A bleeding tumor is more to be resected than an obstructive one for which a by-pass might be recommended. In a general manner, oncologic rules of resections must respect the followings: little free margin on surrounding organs, inutility of lymph node dissections, unless it is required to obtain a free margin. There is a lower mortality and morbidity in palliative resections rather than in by-pass without resections. However, by-pass procedures can still be indicated when resection risk appears to be too high (morbidity and mortality) and/or in case of biliary and/or digestive obstruction. Then, a gastroenterostomy and/or a biliary diversion may be realized.

REMOVING PART OF THE STOMACH If your cancer is at the lower end of the stomach that connects with the small bowel (duodenum) you may have only part of your stomach removed. This is called a partial gastrectomy. The position of the tumour in the stomach will affect how much of the stomach is removed. The surgeon will also take out the lymph nodes around your stomach and part of the omentum (the sheet of connective tissue that holds the stomach in place). After the operation you will have a much smaller stomach but the valve (cardiac sphincter) between your food pipe (oesophagus) and stomach will still be there. The scar from the operation will be across your abdomen.

REMOVING THE STOMACH If your cancer is in the middle of the stomach you may need to have your whole stomach removed. This operation is called a total gastrectomy with a Roux-en-Y reconstruction. After the operation your food pipe (oesophagus) is joined directly to your small bowel. The scar from the operation will be up and down (vertical) or across your abdomen (horizontal). Your surgeon will also remove the lymph nodes around your stomach and part of the omentum. For some cancers in the upper part of the stomach or close to the area where the food pipe joins the stomach (the oesophagogastric junction) an extended total gastrectomy may be done. In this operation, the surgeon removes the whole stomach, the lymph nodes, the spleen and part of theomentum. They also remove part of the pancreas if it has been affected by the cancer.

KEYHOLE SURGERY (LAPAROSCOPIC GASTRECTOMY)

Keyhole surgery is also called minimal access surgery or laparoscopic surgery. It means having an operation without needing a major incision (wound site). The surgeon uses an instrument that is a bit like a bendy telescope (laparoscope). The laparoscope is connected to a fibre optic camera that shows pictures of the inside of the body on a video screen. The laparoscope also has small instruments that fit down the tube. The surgeon can manipulate these and watch what they are doing on the screen. Normally, the surgeon has to use more than one entry site and you have a few small wounds, each an inch or so long. A larger cut may be necessary in some people. It is possible for an experienced surgeon to remove the whole of your stomach, or part of it, using laparoscopic surgery. Some trials have shown that laparoscopic surgery is less traumatic than a single large wound and recovery time may be quicker. It may have fewer complications

than normal open surgery. But other trials have shown that laparoscopic surgery may take longer and some doctors are concerned that it may be difficult to remove enough lymph nodes. The National Institute for Health and Clinical Excellence (NICE) have issued guidance on laparoscopic gastrectomy. They have decided that this procedure is both safe enough, and works well enough to be used as part of NHS treatment. But they stress that you should only be offered this type of surgery for cancer if it is suitable for your individual condition. And if you do have this type of surgery, it must be done by a surgeon trained in laparoscopic techniques and experienced in using them. NICE also state that the results of this type of surgery should continue to be monitored. If you want to find out if this type of surgery is suitable for you, you can talk to your surgeon. You may need a referral to a specialist surgeon with particular experience in laparoscopic surgery

REMOVING THE STOMACH AND PART OF THE FOODPIPE If your cancer is near where your stomach joins your food pipe (oesophagus) you may need part of your food pipe removed as well. This is called oesophagogastrectomy. With this operation, the lowest third of your stomach is kept and made into a tube. The remaining oesophagus is joined onto this part of your stomach. Because your food pipe has to be operated on, you are likely to have 2 scars. Your surgeon can remove the stomach and food pipe through an abdominal wound and chest wound. So you will have a scar across part of your chest, along one of the ribs, as well as down the middle of your tummy (abdomen).

Removing lymph nodes around the stomach

During your operation the surgeon will remove all of the lymph nodes close to your stomach and those along the main blood vessels supplying the stomach. This is because the lymph nodes may contain cancer cells that have broken away from the main tumour. Taking the nodes out reduces the risk of cancer coming back. This is called a D2 lymph node dissection. You have to be very fit to have an operation where the lymph nodes along the main blood vessels are removed. So this operation is not suitable for everybody. In this situation, your surgeon may just remove the lymph nodes closest to your stomach instead (a D1 lymph node dissection).

Eating after stomach surgery

If only part of your stomach is removed you will need to eat small amounts of food more often at first. But your remaining stomach will gradually stretch so that you can eat more at a time. If you've had most or all of your stomach removed, you may eventually be able to eat normally again, but this may take some months. You will also need to have injections of vitamin B12 for the rest of your life to prevent anaemia and nerve problems. There is information about diet after stomach surgery in the living with stomach cancer section. For a while before or after stomach surgery you may need to have liquid food directly into your bowel. There is information about this type of nutritional support in our section on coping physically with cancer. You will have information about this from your dietician and clinical nurse specialist. It is common to have diarrhoea for some months after stomach surgery. This can be very upsetting and you may feel weak for a time. There is information about coping with diarrhoea in the living with stomach cancer section.

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AFTER PARTIAL GASTRECTOMY

BEFORE GASTRECTOMY

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BEFORE ESOPHAGOGASTRECTOMY

AFTER OESOPHEGO GASTRECTOMY