WRITTEN BY Mr TCB DEHN MS FRCS and Mr MI BOOTH FRCS
CONSULTANT LAPAROSCOPIC AND UPPER GI SURGEONS

For anyone, receiving news of the diagnosis of cancer comes as a shock. This leaflet is written for you to explain the clinical problem of gastric (stomach) cancer to you and how you may be investigated and treated. If anything in this leaflet is not clear, do not be afraid to ask any of the Upper Gastrointestinal (UGI) Specialist team caring for you. Our names and telephone numbers are on the back of this leaflet: we are here to help.

A cancer arises when the cells which line the upper intestine multiply beyond the normal control mechanisms of the body. In the stomach this process may lead to a number of different symptoms. It may cause a blockage of the exit of the stomach resulting in vomiting. There may be a notable loss of appetite or weight, or symptoms of indigestion. Sometimes a cancerous growth can bleed; this may result in you becoming short of blood (anaemic), or you may vomit blood.
In general the main treatment of gastric cancer is by surgery. This is usually a major operation.

Staging investigations
Any cancerous growth, whatever organ it arises in, may spread to other organs such as the liver or lungs. This is called "secondary spread". Surgery is not usually recommended if secondary spread has occurred and some other form of treatment is offered. In order to minimise the possibility of undergoing unnecessary surgery in these circumstances, you will undergo several investigations to ascertain whether any such spread has occurred. These are called "staging" investigations. They are not individually 100% accurate, but when all are completed, the accuracy of diagnosing the presence of secondary spread is around 90%.

Not all patients will have all, or even any, of the staging investigations. Some patients will decide they do not wish to undergo surgery, whilst others may have other medical problems such as heart or lung disease which would make surgery and anaesthesia too risky to contemplate. If secondary spread is picked up on the first staging investigation, you will not be asked to undergo further staging tests: a variety of non-surgical methods of treatment will then be discussed with you.

Types of Staging Investigations
1 CT scan (body scan)
This is an X-ray. You lie in something akin to a large torpedo tube and the machine takes x-ray "slices" of your chest and abdomen. If this is normal you may proceed to:

2 Endoluminal Ultrasound (EUS).
This is like the gastroscopy (endoscopy) you will have already had to diagnose your stomach cancer. It is performed under intravenous sedation. A special endoscope is used to measure the thickness of the growth in your stomach. It can also make an assessment of whether or not the local glands (lymph nodes) are affected by the cancer.

3 Laparoscopy.
This is a small operation carried out under a general anaesthetic. Some patients can go home the same day, others may need to stay in overnight. Between one and five small incisions are made on your abdominal wall and a camera is used to inspect the inner surface of the abdominal cavity: if necessary samples of fluid or tissue may be taken from within the abdominal cavity.

Next stage
Once all your staging investigations are completed, we will discuss them at our "multi-disciplinary team meeting". This is where we meet up with our consultant colleagues from other specialities who may be involved with your overall care (the members of this multi-disciplinary team are detailed at the end of this leaflet). Decisions about the treatment that you will be advised to have are made jointly at this meeting.

If all the staging investigations are normal and you wish to have surgical treatment, we may advise you to meet with an oncologist (a specialist in the treatment of cancers using chemotherapy or radiotherapy) prior to having an operation. This is because such treatment may be recommended after an operation, and some further tests may be required to prepare for this. The pros and cons of this treatment will be discussed with you, since not all patients are suitable for post-operative chemo-radiotherapy.

Thus the whole process from diagnosis through staging to the start of treatment may take several weeks. Although this can seem a long time, it is vital for your treatment that proper staging and specialist discussion is undertaken to prevent unnecessary surgery.

Nutrition
During the period of pre-operative treatment, it is important that you maintain a high-protein and high-calorie dietary intake. If swallowing solid food is difficult you will be given advice on how best to achieve this. There are many high-energy drinks available. If maintaining suitable nutrition becomes very difficult we may give you supplementary feeds through a very fine bore tube placed in your stomach. This may require a small operation.

Surgical treatment for gastric cancer
The aim of surgery is to remove the cancerous growth and any adjacent tissue to which the cancer may have spread, including local lymph glands. There are a variety of surgical procedures which your surgeon may use and he will discuss the best approach with you.
In principle, part or all of the stomach has to be removed, and the small intestine brought up to be joined to the part of the stomach that remains, or to the lowermost part of the gullet. The operation is performed through an incision in the abdominal wall. Sometimes the chest wall also has to be opened.

Some surgeons are now able to use keyhole surgery to perform all or part of the operation, but this is very much dependent on the size and location of the tumour, and the personal preference of your surgeon.

Immediately after the operation you will be cared for on the surgical ward, although some patients (particularly those with pre-existing heart or lung problems) may require a stay on the intensive care or high dependency unit prior to returning to the ward. There will be several tubes attached to your body. You will be given fluid intravenously and stomach contents will be drained through a naso-gastric tube (a small tube that passes through your nose into your stomach). There will be a tube draining urine from your bladder, and there may be a tube placed in your intestine in order to give you supplemental feeding.

Post-operative recovery
After your operation you will be seen by your surgeon and his team every day. Over the course of several days the tubes to which you are attached will be removed. Nurses will come round regularly to take recordings of your temperature and drains, to change your dressings and to administer medications. You will be seen by a dietician to help you with your nutrition, and a physiotherapist will encourage you to breathe properly and to help you to move your legs to increase the flow of blood.

In the majority of hospitals undertaking this kind of surgery, post-operative pain relief is very efficient and is usually given by an epidural anaesthetic. Sometimes an epidural anaesthetic is not feasible and you may be given painkilling drugs intravenously. Often you can control the amount of these drugs that you receive by a mechanism known as "patient control analgesia". In this method you wear a little button around your wrist, which you can press every time you feel some discomfort. A small amount of painkilling medicine is automatically injected into you each time you press the button.

Following completion of the operation, the piece of stomach that the surgeon has removed will be sent off for analysis by the pathology department. Results of this usually take seven to ten days to be returned to the surgeon. As with the pre-operative staging investigations, the results of this analysis will be discussed in the multi-disciplinary team meeting. Your surgeon will then discuss with you the results and any implications for further treatment.

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Consent for gastrectomy
Having read the attached information leaflet you may feel more able to sign the informed consent document.
All operations, however minor, are subject to an element of risk. Surgery and anaesthesia are a lot safer now than they were twenty years ago, but not all operations go according to plan. It is important that you are aware of and understand these risks.

The following is a list of the principal complications associated with this type of surgery:
1. Chest infection/pneumonia
2. Clots forming in the legs and travelling to the lungs (deep venous thrombosis and pulmonary embolism).
3. A leak at the join of intestine. This may require a lengthy period of treatment including supplementary nutrition and tube drainage of any leaking intestinal contents. Occasionally further surgery is needed to secure the leak.
4. Removal of the spleen. Sometimes this is necessary since it may get injured during dissection of the stomach. If this does occur, you will need to take an antibiotic tablet (usually penicillin) daily.

Because of the magnitude of the surgery, the seniority of many patients suffering from this disease and the presence of cancer, a few patients will, unfortunately, die from complications of surgery. The United Kingdom mortality for this operation is around 10%, although many centres are now reporting much lower mortality rates. As with any treatment for cancer, the risks of the treatment must be weighed up against the risks of not having the treatment and continuing with the disease.

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We hope you have found the above information useful. Please remember that this may not be the exact protocol followed in your own hospital, and there will be variations on the above theme.

Upper GI Cancer Multi-Disciplinary Team members
Mr Thomas Dehn (Consultant Laparoscopic and Upper Gastrointestinal Surgeon). Tel: 0118 9878623
Mr Michael Booth (Consultant Laparoscopic and Upper Gastrointestinal Surgeon). Tel: 0118 9878678
Dr James Gildersleeve (Consultant Oncologist). Tel: 0118 9877861
Dr Jonathan Booth (Consultant Gastroenterologist). Tel: 0118 9877347
Dr Robert Menai-Williams (Consultant Histopathologist)
Dr Naid Rahim (Consultant Radiologist)
Ruth Moxon (Upper GI Cancer Nurse Specialist) Tel: 0118 987748

Other useful contact numbers

Endoscopy department. Tel: 0118 9877459
X-ray department. Tel: 0118 9877923 or 0118 9877924
Dieticians department. Tel: 0118 9877116

Outcome of surgery >>