Stomach Cancer Surgery

Patients with gastric cancers are evaluated by surgical oncologists that specialize in gastric cancer and work in the context of a comprehensive multidisciplinary team in the Tucker Gosnell Center for Gastrointestinal Cancers

Surgical Oncologists have undergone additional specialty training in oncology, and offer the highest degree of specialization and expertise. Gastric cancer surgery is generally considered complex surgery and published data have demonstrated that hospitals and surgeons with the highest volume experience with specific operations have the lowest complication and death rates. Recognizing the relationship between frequency of performing an operation and the quality of outcomes, each surgeon in the Division of Surgical Oncology focuses his or her clinical practice on the management of one of two diseases.

Patients with gastric cancers are evaluated by surgical oncologists that specialize in gastric cancer and work in the context of a comprehensive multidisciplinary team in the Tucker Gosnell Center for Gastrointestinal Cancers. Patients with gastric cancer are evaluated in multidisciplinary sessions, where they can meet with a surgeon, radiation oncologist and medical oncologist, have their x-rays and pathology slides reviewed, and receive definitive treatment recommendations in a single visit. This team also collaborates closely with the genetic counselors in the Center for Cancer Risk Assessment is offered to assess hereditary risk in young patients and patients with strong family histories of gastric cancer.

SurgerySurgery remains the primary treatment modality for stomach cancer. Ideally, tumors should be removed with a margin of normal tissue of about 5 centimeters (two inches). However, stomach cancers often arise in difficult anatomic locations and may require extensive surgical expertise to remove in their entirety with the best possible margin. Stomach cancers arising in the distal or lower portion of the stomach often can be removed without removal of the entire stomach (subtotal gastrectomy). Cancers arising in the proximal or upper stomach usually require removal of the entire stomach (total gastrectomy) and connection of the small bowel to the esophagus. These procedures can be technically demanding and should be reserved for experienced surgeons.

There is uniform agreement that the regional lymph nodes around the stomach should routinely be removed during resection of a stomach cancer. This lymph node dissection is called a D1 lymphadenectomy. However, a recent large multi-center U.S. trial showed that the majority of surgeons in this study did not even perform this minimum lymph node dissection. There is ongoing controversy over whether a lymph node resection beyond a D1 lymphadenectomy is beneficial. Experienced stomach surgery centers, especially in Japan, have argued that a more extensive lymph node dissection that incorporates the next echelon of lymph nodes (D2 lymphadenectomy) improves outcome in stomach cancer patients. The two largest Western trials examining this issue did not find a benefit to D2 lymphadenectomy. However, these studies had several flaws including a technique of D2 lymphadenectomy that unnecessarily included resection of the spleen and portion of the pancreas, leading to increased complications and mortality from surgery.

We work collaboratively with surgeons in Massachusetts General Hospital’s Gastroesophageal Surgery Program, who specialize in complex surgical techniques to treat patients with gastric and esophageal cancers. 

The surgical oncologists at the Cancer Center have all received specialty training in stomach cancer surgery and believe that stomach resection along with D2 lymphadenectomy can be performed safely and may improve survival in a subset of patients with stomach cancer.

Surgical oncologists at the Cancer Center are also experienced in the use of minimally invasive surgery (or laparoscopic surgery) techniques to rule out peritoneal spread of stomach cancer and offer alternative types of surgical resection. For example, gastrointestinal stromal tumors (GIST) are sarcomas that occur on the stomach wall and are often amenable to laparoscopic resection. Minimally invasive surgery offers the advantages of less post-operative pain, shorter hospital stay, and earlier return to normal activity.

Learn more about the Gastroesophageal Surgery Program 

Chemotherapy and Radiation TherapyStomach cancers have the ability to spread to distant sites, most frequently to the peritoneum, liver, and lung. Chemotherapy may be beneficial to patients even if no sites of distant disease are identified in order to kill microscopic foci of tumor cells. If macroscopic distant disease is identified, chemotherapy may be beneficial in decreasing the growth and spread of disease.

Chemotherapy is usually given in combination with radiation therapy after surgical resection of the stomach cancer. A recent trial published in the New England Journal of Medicine showed that patients receiving chemotherapy and radiation therapy after surgical resection of stomach cancer had improved survival compared to those treated with surgery alone. Thus most patients at the Cancer Center with completely resected stomach cancer are treated with post-operative chemotherapy and radiation therapy. Learn more about treatment for stomach cancer.