• 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

Gastrectomy

• 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