Cancer of the stomach is a rather malignant disease. Even today the best option for treatment is surgery. Of course this is true only, if the whole tumor can be removed.
The symptoms and signs are few in the early stages of the tumor. A chronic ulcer or chronic pain should always arouse suspicion and lead to an endoscopy. Unfortunately patients treat their stomach aches with medication they can buy over the counter without prescription and therefore come late for gastroscopy.
The diagnosis is made by endoscopy and biopsy. In order to asses operability (i.e. complete removal of all tumor can be achieved) sonography and a CT-scan is needed.
If operability is verified, the patient proceeds to surgery. If on the other hand operability is not certain, we prefer to submit the patients for a preoperative chemotherapy. The rational for this is, that we want to downstage (i.e. make the tumor smaller) the patient and then do a curative operation including all the tumor tissue. Chemotherapy after an incomplete resection of the tumor has rather poor results. All patients with gastric cancer are discussed in our tumor board with all the work up and information before any decision for treatment is made.
Surgery for gastric cancer has to be as radical as possible. This often means the resection of the whole stomach. The tumor often spreads under the surface of the mucosa like the legs of a spider or the tentacles of an octopus and is in fact bigger than we can see with our eyes. see figure 1 see figure 2
Only in smaller tumors of the lower end of the stomach and with a certain histological constellation can a subtotal (4/5) resection be allowed without risk of incomplete tumor resection. see figure 1 see figure 2
Another important aspect of gastric surgery is radical removal of the draining lymph nodes. Unlike in the large bowel, where the lymphatic system is rather well organized and within physical borders of the mesocolon (and can therefore be removed easily), lymphatic drainage of the stomach is rather chaotic and surgical removal is a tedious job. My surgical teacher, Prof. J.R. Siewert standardized the technique of gastric lymph adenectomy in the late 80ies and his procedure is the worldwide gold standard today.
Life without a stomach is possible. Of course we always try to preserve a small portion of the stomach, if the tumor size and stage allow us. After total gastrectomy the passage of food is reconstructed with the upper small bowel (Jejunum) and after a while even a limited reservoir function returns, enabling the patient to eat almost normal meals. During the first months after gastrectomy many small meals (at least 6-8/day) are necessary. Intake of fluid together with food must be avoided. If necessary, high calorie supplemental food must be added to the diet of our patients. The aim is to prevent severe weight loss, because it will be very difficult to regain weight again after gastrectomy.