Gastric cancer is the cancer originating in the esophagus, esophagogastric junction and stomach.
Most of gastric cancers are adenocarcinomas, subdivided according to histological appearances into diffuse (undifferentiated) and intestinal (well differentiated) types.
It is the 4th most common cancer and the 2nd most common cause of cancer-related deaths worldwide.
Most common sites of gastric cancer are the proximal lesser curvature, cardia and esophagogastric junction.

Surgical Intervention

  • Surgery with lymph node dissection is the primary treatment option in early stage/resectable gastric cancer
    • Though majority still relapse following resection, it is potentially curative
    • For ≥ stage 1B combined modality approaches are standard
  • Standard goal is complete resection with adequate margins (≥ 4 cm)
    • Extent of resection is determined by preoperative stage of the cancer
  • Gastrectomy with D1 or a modified D2 lymph node dissection with a goal of examining at least 15 lymph nodes for patients with localized resectable cancer

Endoscopic therapies

  • For the treatment of patients with early stage gastric cancer, endoscopic mucosal resection (EMR) & endoscopic submucosal dissection (ESD) have been used as an alternative to surgery
    • ESD is the treatment of choice for most gastric superficial neoplasmic lesions
  • It has been shown that en-bloc excision by endoscopic submucosal dissection (ESD) is more effective than endoscopic mucosal resection (EMR) in curing early gastric cancer
  • For lesions ≥ 5 mm in diameter, complete resection rates were significantly better for endoscopic submucosal dissection (ESD) while in lesions ≤ 5 mm in diameter, there were no difference between endoscopic mucosal resection (EMR) & endoscopic submucosal dissection (ESD) rates regardless of location
  • T4 tumors require en bloc resection of involved structures
  • Indications for endoscopic mucosal resection (EMR) includes:
    • Carcinoma in situ
    • Well or moderately differentiated lesions
    • Confined to the mucosa
    • Not ulcerated
    • Without lymph node metastases or lymphovascular invasion


  • Distal, subtotal or total gastrectomy is recommended for T1b-T3 tumors

Subtotal gastrectomy

  • A procedure that involves removal of a section of the stomach, & may include part of the esophagus or 1st part of the duodenum; the remaining section of the stomach is then reattached
  • Preferred approach for distal gastric cancers
  • May be carried out if a macroscopic proximal margin of 5 cm can be achieved between the tumor & esophagogastric junction
  • Eating is much easier after surgery

Total gastrectomy

  • A procedure involving the surgical removal of the stomach as a whole, including adjacent lymph nodes & omentum, as well as part of the esophagus that is attached to the small intestines
  • Preferred gastrectomy for patients with stage IB-III gastric cancer
  • Proximal gastrectomy & total gastrectomy are both indicated for proximal gastric cancers & are typically associated with postoperative nutritional impairment
    • A margin of 8 cm is recommended for diffuse type cancers

Lymph node dissection

  • It is the removal of regional lymph nodes
  • It should be included in gastric resection
  • Classification depending on the extent of lymph nodes removed during gastrectomy:
    • D0 refers to incomplete resection of N1 lymph nodes
    • D1 involves gastrectomy & the removal of the involved proximal or distal part of the stomach or the entire stomach, including the greater and lesser omental lymph nodes
    • D2 involves D1 with additional removal of the anterior leaf of the transverse mesocolon & all the nodes along the corresponding arteries

Laparoscopic surgery

  • An alternative to open surgery due to potential benefits of:
    • Less blood loss
    • Reduced postoperative pain or morbidity
    • Reduced recovery time
    • Early return to normal bowel function
    • Reduced hospital stay
  • Although there are concerns about long-term outcomes & the possibility for reduced nodal harvest

Palliative surgery

  • Surgeries that will aid the patients with unresectable gastric cancer control the cancer or prevent or relieve symptoms or complications
  • Subtotal gastrectomy can help in problems of bleeding, pain or blockage in the stomach
  • Gastric bypass (gastrojejunostomy) can treat or prevent large tumors that block food from leaving the stomach
    • For selected patients who will be receiving postoperative chemoradiation, placement of a venting gastrostomy or jejunostomy feeding tube may be considered
  • Endoscopic tumor ablation helps to stop bleeding or help relieve blockage without surgery
    • For short-term control of bleeding
  • Stent placement helps keep the opening at the beginning & end of the stomach open & allows food to pass through it
  • Feeding tube placement is done to help in the liquid nutrition that can be put directly into the tube
  • Limited gastric resection, even with positive margins, is acceptable for unresectable tumors for symptomatic palliation of bleeding
    • Presence of peritoneal involvement, distant metastases, or locally advanced disease (eg invasion or encasement of major blood vessels) are contraindications for resection
  • Routine or prophylactic splenectomy should be avoided if possible

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