Surgical Procedures:
Surgery for Gastric Cancer
Surgery provides the only chance for cure of gastric cancer. The type of operation performed depends on the site of the cancer. For most cancers of the stomach, a procedure known as radical, subtotal gastrectomy is performed (i.e. some part of the stomach remains). For cancers high up in the stomach, total gastrectomy may be required (all of the stomach is removed).
What does surgery involve?
Gastrectomy or removal of the stomach for cancer is major surgery requiring full hospital admission for 7-10 days.
The operation itself involves a full general anaesthetic. Once anaesthetised, several procedures are carried out to ensure the safety of the patient prior to surgery commencing. These usually include
- Insertion of urinary catheter - allows careful measurement of kidney function during and after the operation.
- Nasogastric tube placement - fine tube passed through the nose and into the stomach to keep the stomach deflated.
Once these tasks have been completed, the operation itself commences. This involves an upper, midline abdominal incision about 25cm in length to allow access to the stomach. Despite previous staging procedures, the abdominal cavity is thoroughly examined to exclude metastatic disease which staging tests sometimes miss. This occurs rarely with thorough preoperative staging techniques used by Dr Fenton-Lee.
Once this has been done, the stomach and surrounding structures are mobilised or free from their attachments. To optimise the cure rate, a wide surgical margin around the tumour is taken. This includes resecting many of the lymph nodes that drain the stomach, which is where cancer first spreads. Extensive lymph node dissection has shown to improve survival rates for gastric cancer as is routinely practised by Dr Fenton-Lee.
Once the stomach and lymph nodes have been mobilised, the cancerous part of the stomach, as well as wide margin of normal tissue is removed. Occasionally, if the tumour is adherent or is close to the spleen, it must also be removed.
The last part of the procedure involves reconstructing the integrity of the gastrointestinal tract. This is done by re-anastomosing the two ends of divided bowel either by using specialised stapling devises or by suturing by hand. In the case of subtotal gastrectomy, the small intestine is anastomosed to the remaining stomach. In total gastrectomy. the small bowel is anastomosed to the oesophagus.
The abdomen is then washed out to reduce the chance of infection and the wound closed. Dressings are finally applied to the wound.
The operation takes approximately 2-3 hours to complete. The specimen is sent to pathology for examination which normally takes 5-7 days to complete.
What will i be like after the operation?
Upon arrival to the ward following surgery, the nasogastric tube and urinary catheter remain. In addition, a canula or fine tubing inserted into a vein remains to administer fluids and medications intravenously. Most patients will also have special stockings and twice daily injections of an anti clotting medication to help prevent deep vein thrombosis.
No oral intake is allowed for the first 4 or 5 days to allow the bowel to recovery from surgery. Pain control, early mobilisation and regular physiotherapy to reduce the chances of chest infections are routine post operative treatments.
Diet is slowly introduced over the following few days. The nasogastric tube and catheter are removed as soon as possible which is usually 2 to 3 days post operatively. The canula is no longer required once oral intake is adequate.
Patients are able to return home once they are mobilising independently, pain control is achieved with oral medications and they are tolerating a normal diet. This is generally achieved between 7 to 10 days following the operation.
As much of the stomach has been removed, smaller meals lead to the feeling of fullness. This means that dietary adjustments are required to maintain good nutrition. The hospital nutritional services are used to educate on dietary changes needed.
Prior to discharge, pathology results are discussed. If other forms of treatment such as chemotherapy are considered, this is arranged with specialist oncologists at St Vincent's Hospital during admission.
Due to the extent of the operation, rehabilitation and recovery continues at home. Full recovery often takes months to complete. Most people are back to full activities after 6-8 weeks. Post operative follow-up with Dr Fenton-Lee is arranged prior to discharge.
What complications can occur?
Despite the complexity and extent of this procedure, complications are rare, but include
- Bleeding/Infection
Significant bleeding during or following the operation is rare. Post operative infection within the abdomen or wound infections are also rare complications. These complications are reduced by the administration antibiotics at the time of operation.
- Anastomotic leaks
Leaks at the site of re-anastomosis are rare. Minor leaks can be treated without re-operation, but most leaks require repair with surgery.
- Anastomotic stenosis
Narrowing or stenosis at the site of anastomosis is also uncommon. Re-operation is sometimes required.
- Dumping Syndrome
This is a syndrome that occurs because much of the stomach is removed which leads to ingested food coming into contact with the small intestine sooner than normal. This normally has no effect on most patients but can lead to diarrhoea 30-60 minutes following meals. In most cases, the body adapts to the stomach being removed and symptoms completely resolve. Occasionally, dietary changes reducing carbohydrate intake are required.
- Vitamin B12 deficiency
The stomach plays an important role in vitamin B12 absorption. With partial gastrectomy, B12 absorption is usually not affected, but vitamin supplementation may be required.
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