Gastric Cancer Surgery - Stomach Cancer Surgery

Free consultation

Send the endoscopy report with the tumour distance from the junction

Where the tumour sits inside the stomach decides whether part of it can be kept, so the endoscopy report matters as much as the scan. Send that report with the measured distances, the biopsy pathology including HER2 and mismatch repair results if they were done, the staging CT as image files, and any PET or laparoscopy findings. What comes back is an opinion on whether a distal resection is possible or the whole stomach has to go, whether chemotherapy should come first, and what eating would look like afterwards. The review costs nothing and carries no obligation.

How much stomach comes out

Position governs this, and size follows behind it. A tumour low in the stomach can be removed with the lower two thirds and the upper third left in place. A tumour high in the body or at the junction with the oesophagus forces the whole organ out, because a clear margin above it cannot be obtained any other way. That single anatomical fact decides most of what follows.

This table scrolls sideways on a narrow screen. Swipe or drag to see every column.

How much difference keeping part of the stomach makes against losing all of it is larger than most patients are told, and it has now been measured inside a randomised trial and not estimated from registries.

So the position is unambiguous where the anatomy allows a choice. Keep the stomach. What that does not mean is that a total gastrectomy represents a failure, because for a tumour high in the stomach it is the only operation that removes the cancer, and removing the cancer is the point, so a surgeon who recommends taking the whole organ is answering the anatomy in front of them rather than reaching for the bigger operation out of caution.

How many nodes come with it

Stomach cancer spreads to lymph nodes early and in a predictable order, so the node dissection is graded and not merely described. D1 takes the nodes sitting along the stomach itself. D2 goes further, clearing the stations along the named arteries that supply it, and it is the standard of care for any resectable gastric cancer that is more than superficial.

That standard was hard won, and the trial that established it deserves reading honestly rather than in summary.

Two things follow from that for anybody choosing where to be treated. A D2 dissection performed badly is worse than a D1 performed well, and the difference between those two comes down to surgical volume and not to equipment. And the node count on your pathology report is the single most useful number for judging whether the operation was done properly, so ask for it, and read it rather than filing it.

Keyhole, robotic or open

For early gastric cancer this was settled a decade ago in favour of keyhole surgery. For locally advanced disease the question was whether a surgeon working through small incisions could still clear the node stations properly, and two large trials from Korea and China were built to answer it.

Pooling the individual patient data from both, 1,820 patients having distal gastrectomy for locally advanced cancer, five year overall survival was 82.7 percent after keyhole surgery and 83.3 percent after open, and recurrence-free survival 76.9 percent against 77.9 percent. Neither difference approached significance. Short-term recovery favoured keyhole surgery, with the one exception that anastomotic leak occurred more often.

One subgroup came out differently and it deserves stating. In tumours that had grown through the full thickness of the stomach wall, classified as pT4, recurrence-free survival was worse after keyhole surgery. That counts as a single subgroup finding from a pooled analysis and not a trial result, so it is a reason for caution rather than a prohibition, and it is a fair thing to raise if your own staging says T4.

Robotic surgery does the same operation with articulated instruments, and it is used increasingly for the node dissection around the vessels where the movements are fine, while open surgery keeps its place for bulky tumours, for extended resections taking neighbouring organs, and for the moment a surgeon judges the view inadequate and converts.

Chemotherapy before surgery

Outside the very earliest cancers, surgery is no longer the first thing that happens. Drugs come before and after it, and the regimen changed in a way that materially improved survival.

German investigators randomised 716 patients with locally advanced stomach or junctional cancer to the older three drug regimen or to a four drug combination given as four cycles before surgery and four after. Median overall survival came to 50 months with the newer regimen and 35 months with the older one, a hazard ratio of 0.77, while serious side effects and toxic deaths were no more common and hospital admission for toxicity ran the same in both groups.

Fifteen months of median survival is a large gain, and it comes with a cost in time.

Four cycles beforehand takes roughly two months, then surgery a few weeks after the last one, then four more cycles afterwards. For an international patient that shapes the entire plan. It usually means either a long stay or a split, with the chemotherapy given at home and the surgery here, and that split only works if the two teams agree the timing in writing before the first cycle. Raise it at the first consultation, because discovering the operating date has moved by two months is the most disruptive thing that happens to people arranging this from abroad.

The operation and the join

Three to five hours, longer for a total gastrectomy than a distal one, and longer again where neighbouring organs are involved.

Some units place a feeding tube into the small bowel at the same operation, particularly after a total gastrectomy or where the patient arrives underweight, and it is used for a few weeks while eating builds up. Accept it where it is offered, because losing weight in the month after this operation is much easier to prevent than to reverse.

Of the joins, the one to the oesophagus is the fragile one. It sits high, its blood supply is the poorest in the reconstruction, and it is why a total gastrectomy carries the complication profile the Dutch trial measured.

What goes wrong

Anastomotic leak dominates, and the figures from the Dutch trial give the honest shape of it. Around 3 percent after a distal resection and close to 19 percent after a total one, appearing between day four and day ten with fever, pain, a rising pulse or a patient who simply is not improving. Management runs from antibiotics and a drain placed by a radiologist through to a return to theatre, and a leak at the oesophageal join is the one that keeps people in hospital for weeks. Chest complications come next, and they arrive more often than patients expect after an operation on the abdomen. The incision sits high, breathing hurts, and pneumonia followed in 22 percent of total gastrectomy patients in that same trial, which is a rate that surprises people who came in worrying about their stomach and had not thought about their lungs at all. Breathing exercises and getting out of bed on the first day are the countermeasures, and they are effective. Then the shorter list. Bleeding. Duodenal stump leak, which is specific to this operation and presents late. Pancreatic fistula where the dissection ran close to the pancreas. Abscess in the space under the diaphragm. Delayed emptying of the stomach remnant, which resolves with time and patience. Atrial fibrillation. Clots in the legs or lungs.

Death within 90 days is uncommon in high volume units and it rises with the extent of the resection, with age, and with poor nutrition on arrival, which is the one item on that list that can be improved before the operation rather than after it.

Eating afterwards

Patients come back to this section more than any other, and most hospital pages give it three lines. The stomach does four jobs. It holds a meal, it grinds it, it releases it slowly into the small bowel, and it produces acid and the protein that lets you absorb vitamin B12. Remove it and every one of those jobs stops.

The first three months

Feeding starts early, frequently on the first day after surgery with sips and clear fluids, because early feeding shortens the stay and helps the join heal instead of threatening it, and from there fluids build to full liquids, then to soft moist food by the time you leave hospital, then to a normal texture across several weeks. What does not return is the volume. Six to eight small meals a day replaces three, and that is not a temporary measure for the recovery period but the way you will eat from now on. Drink between meals, never with them. Stop about half an hour before eating and wait half an hour afterwards, because fluid takes up the space food needs and pushes the meal through faster, which is precisely the mechanism behind the symptom described next.

Dumping syndrome, and what to do about it

When a meal arrives in the small bowel too quickly, fluid is drawn out of the circulation to dilute it. Fifteen to thirty minutes after eating you feel bloated, crampy, nauseated, sweaty and light-headed, with a racing heart and often diarrhoea. Doctors call that early dumping. Late dumping happens one to three hours after a meal, when a surge of sugar into the bowel provokes an insulin response that overshoots and leaves you shaky, sweating and confused until you eat something.

Both occur commonly after gastrectomy, both frighten people who were not warned, and both respond to management.

1. Eat small and often, chew thoroughly, and take at least twenty minutes over a meal.
2. Separate drinks from food by thirty minutes on either side.
3. Cut simple sugars. Fruit juice, sweet drinks, cakes and puddings are what provoke both forms of it.
4. Put protein and fat into every meal. Both slow the passage of food where sugar accelerates it.
5. Lie down for twenty to thirty minutes after eating if early dumping is a problem, which slows things further.
6. Ask about medication if the measures above are not enough, because drugs that slow gastric emptying exist and are underused.

What the stomach was absorbing for you

Vitamin B12 heads the list, and it is neither optional nor negotiable, and the rest follow from the same loss of acid and lining.

This table scrolls sideways on a narrow screen. Swipe or drag to see every column.

Levels get checked on blood tests at intervals, and a subtotal resection needs the same monitoring even though the deficiencies are less severe.

Weight and strength

Expect to lose weight, and expect the amount to alarm you before it stabilises. Ten to fifteen percent of body weight in the first six months is a common range after total gastrectomy and less after a distal resection, and most people then plateau instead of continuing to fall. Where weight keeps dropping past six months, something specific is usually behind it, meaning dumping that has never been addressed, a stricture at the join, exocrine pancreatic insufficiency or simple fear of eating, and every one of those has a treatment. Muscle goes before fat if protein intake is not deliberate. Aim for protein in every one of those six to eight meals, and see a dietitian instead of improvising, because this is the single area where specialist input measurably changes the outcome and is the most commonly omitted part of the aftercare, particularly for someone who was treated in one country and went home to another.

Fatigue lasts three to six months and improves in a way that is easier to see month by month than week by week, and walking daily while building the distance does more for it than resting ever will. Driving returns at around four weeks after keyhole surgery and six or more after an open operation, judged by whether you could brake hard without hesitating. Desk work follows at a similar point and physical work at around three months.

How long you stay

Three to four weeks in the country for surgery alone, and a good deal longer if the chemotherapy is given here as well.

Assessment takes four to six days. Endoscopy repeated or reviewed with the tumour position measured, a staging CT of chest, abdomen and pelvis, PET where the picture is unclear, laparoscopy with peritoneal washings in units that do it routinely, nutritional assessment with albumin and weight history, and a tumour board before a date is set. The nutritional assessment is not a formality, and where it identifies significant weight loss the operation may reasonably be delayed a fortnight while that is corrected. Expect six to eight nights on the ward after a distal resection and eight to twelve after a total gastrectomy, with the join and the return of eating deciding the exact day. Add a week to ten days nearby afterwards, because that period covers the wound check, the pathology discussion, the first proper dietitian session, and the confirmation that you are eating well enough to spend twelve hours on an aeroplane without it becoming an emergency.

Flying gets cleared at around three weeks after an uncomplicated operation, with a healed wound, no fever, no undrained collection, an intake that is holding your weight steady and an agreed plan for clot prevention. Leaving earlier carries real risk, because a leak declares itself in the second week and because the dietary problems that make people miserable surface in exactly that window, when somebody who knows the operation should be within reach.

What drives the cost

Distal and total gastrectomy carry different theatre times, different complication rates and different lengths of stay, so a single figure for stomach cancer surgery tells you very little. Eight things move the total.

1. Whether the whole stomach comes out or part of it stays. That one decision moves theatre time, complication risk and ward days together.
2. Whether neighbouring organs come out too, meaning the spleen, the pancreas tail or part of the colon.
3. The surgical approach, since keyhole and robotic platforms carry instrument costs per case that open surgery does not.
4. The staplers and circular anastomosis devices the reconstruction consumes, which is a real line item in this operation.
5. Whether a staging laparoscopy is done as a separate procedure beforehand.
6. Intensive care, planned or otherwise, and the ward days that the join ultimately decides.
7. The pathology, including the node count and the HER2, PD-L1 and mismatch repair testing that guides drug treatment.
8. Chemotherapy before and after the operation, which is the largest item of all and sits outside almost every surgical package.

Nutritional support hides in plain sight. Feeding tubes, supplement drinks, dietitian sessions and the extra days that poor intake adds to a stay are frequently uncosted at the outset and frequently needed. Your own condition moves the total as much as the operation. Weight loss before surgery, low albumin, diabetes, heart and lung disease, previous abdominal surgery and continued smoking each raise the chance of a longer stay and of care nobody budgeted for.

What a quoted price for this operation ordinarily covers is the airport pickup, the pre-admission workup, the operating fees, an agreed count of theatre and ward days, an interpreter, accommodation for you and a companion, and the review appointments before you fly. Sitting outside that figure, in almost every package published in this market, are the tickets home, travel insurance, every ward night past the agreed count, critical care that was not planned for, whatever a complication costs to treat, and all chemotherapy in either direction. Read the exclusion list first and the inclusion list second.

Six questions turn a headline into a quotation. Does the figure assume a distal or a total gastrectomy, and what changes if the frozen section forces the larger operation. Are the staplers and anastomosis devices inside it. Is a staging laparoscopy included. How many ward nights are covered, and what an extra night costs. Is the molecular pathology inside the figure. And whether any dietitian input or nutritional support is included after discharge.

No quotation means anything until a surgeon has read your endoscopy and your scans. That review costs nothing.

Once you are home

Surveillance runs on clinical review, blood tests and CT, at intervals of six months for the first two to three years and annually afterwards, with endoscopy where a stomach remnant was left. Something honest deserves saying about that schedule, because it is rarely said. A secondary analysis of 975 patients from a Korean trial compared those who kept to the follow-up protocol with those who did not, and found recurrence detected more often in the compliant group without any improvement in five year survival, at 84.5 percent against 87.5 percent. Regular follow-up did not predict survival independently. That finding does not mean skip your appointments. Detecting a recurrence early matters for treatment options and for planning, and the study was not designed to answer whether any follow-up is better than none. What it does mean is that the value of the schedule is honest information and not a survival guarantee, and a page that implies otherwise is overselling it.

What genuinely changes outcomes at home is the nutritional half of the plan. The B12 injections, the iron and vitamin D, the bone density check, the dietitian, and somebody reviewing your weight against a number written down on the day you left.

Take home the operative note naming the resection and the reconstruction, the pathology with the node count and the molecular results, the imaging on disc, your discharge weight, the vitamin schedule with doses and intervals, and the follow-up dates. Get it in English. An oncologist at home cannot plan treatment without the node count and the HER2 result, and asking for them six weeks later across a time zone wastes weeks.

Contact the team here for a fever, worsening abdominal pain, vomiting or an inability to keep food down, difficulty swallowing that is getting worse, black stools, or weight that is still falling at six months. A message and a photograph answer most questions within hours.

Frequently asked questions about gastric cancer surgery