Jeffrey M. Hardacre

Introduction

The number and types of gastric procedures performed by surgeons-in-training have changed dramatically over time. With the advent of histamine receptor (H₂) blockers and proton pump inhibitors, as well as the discovery of Helicobacter pylori, surgery for peptic ulcer disease has all but disappeared, with the exception of emergency operations for perforation or bleeding. Concomitant with the decrease in the surgical treatment of ulcer disease has been the dramatic decrease in the incidence of gastric cancer in the United States. Opposing these decreasing trends in the surgical treatment of gastric disease has been the explosion in bariatric surgery during last 10 to 15 years.

Even though many more bariatric procedures are performed than standard gastric resections, the ability to perform partial and total gastrectomy must be part of the surgeon’s armamentarium. Currently, about 21,000 new cases of gastric cancer occur each year in the United States.

Principles of Gastric Cancer Treatment

The treatment of gastric cancer depends on a number of factors; the most important are histologic type and location. This chapter focuses on surgical approaches to the treatment of gastric adenocarcinoma.

The treatment of gastric cancer begins with accurate staging. This includes a complete patient history and physical examination, upper gastrointestinal (GI) endoscopy, and computed tomography (CT) of the chest, abdomen, and pelvis. Endoscopic ultrasound may be useful, particularly when neoadjuvant therapy is being considered. Staging laparoscopy is appropriate, because CT-occult disseminated disease may be found in as much as 30% of patients. Palliative resection usually is not needed with current endoscopic interventions.

Surgical resection, including en bloc removal of lymph nodes and adherent organ(s), remains the mainstay of gastric cancer treatment. However, prospective randomized trials have shown that (1) surgery followed by chemoradiation therapy or (2) chemotherapy followed by surgery followed by more chemotherapy are both better than surgery alone. Given the propensity for gastric cancer to spread within the wall of the stomach, gross margins of 5 to 6 cm are usually needed to ensure negative final, histologic margins. The American Joint Committee on Cancer recommends that at least 16 lymph nodes be assessed for staging.

Surgical Approach for Gastrectomy

The abdomen is explored to evaluate for metastatic disease, usually through an upper midline incision, although some surgeons prefer a chevron incision. Laparoscopic-assisted approaches to gastric resection are increasingly used. Figure 8-1 shows the stomach in situ with its relationship to surrounding structures. Figures 8-1, 8-2, and 8-3, A, show the arterial and venous anatomy pertinent to gastric resection.

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