Surgical treatment of gastric cancer

Surgery is still the main treatment for gastric cancer, and drug therapy is used after surgery according to different pathological examination results. The treatment principle of gastric cancer is: after radical surgery for stage Ia gastric cancer, pathological examination shows that the cancer cells are well differentiated and chemotherapy can be avoided. Patients in stage Ib should undergo chemotherapy after surgery. After radical surgery for stage II gastric cancer, chemotherapy and Chinese medicine should be used, and radiotherapy should be used when necessary. For stage III gastric cancer, as long as the primary lesion allows and the patient can generally withstand anesthesia and surgery, palliative resection or shortcut surgery should be performed to improve the patient's quality of life, and Chinese medicine and chemotherapy should be used after surgery.

1. Surgery

Due to the improvement of gastric cancer diagnosis and treatment, the indications for surgery have been expanded accordingly. At present, except for patients with huge, fixed primary lesions, extensive metastasis to abdominal organs, and cachexia with bloody ascites, as long as the patient's general condition permits, even if there are supraclavicular lymph node metastases and metastatic nodules in the liver, laparotomy should be performed to remove the primary lesion and alleviate symptoms. According to statistics of 11,734 gastric cancer surgeries in China, the surgical rate was 81.9% and the total resection rate was 49.7%. In recent years, the tumor resection rate has increased to about 75%, mainly due to the increase in the resection rate of stage I and II gastric cancer.

(1) Radical resection is divided into radical subtotal gastrectomy and radical total gastrectomy. The scope of radical resection should include the primary lesion together with 2/3 or 4/5 of the distal stomach, the entire greater and lesser omentum, part of the duodenum and regional lymph nodes, and the en bloc resection of locally infiltrated organs, with no residual cancer cells in the stomach or duodenal stump. In addition to the above contents, the expanded scope of radical resection also includes the removal of the entire stomach or the adjacent invaded transverse colon, left lobe of the liver, spleen, body of the pancreas, tail of the pancreas, and lymph nodes. The scope of gastrectomy and the scope of lymph node removal have always been controversial. Radical surgery or the degree of radical treatment can be divided into three levels: A, B, and C according to the scope or degree of the lesion. The standard for grade A is that the range of lymph node removal exceeds the lymph node stations where metastasis has occurred, such as only the first-station lymph nodes have metastasis, and the second-station lymph nodes have been completely removed during surgery, and there is no cancer infiltration within 1 cm of the gastric tangent line. The standard for grade B is that the range of lymph node removal is only the lymph node stations where cancer has metastasized, or even if there is no cancer infiltration at the gastric resection edge, there is cancer infiltration within 1 cm. Grade C means that there is cancer infiltration at the resection edge or there are metastatic lymph nodes, and other metastatic lesions are still left in the body. According to the specific situation of each patient, the key to improving the efficacy of gastric cancer surgery is to perform surgery with the corresponding radical resection range reasonably.

(2) Endoscopic mucosal resection: Complete removal of early gastric cancer under endoscopy was an important development in endoscopic treatment technology in the 1980s. The key to the success of this operation depends on the early stage of canceration and the absence of lymph node metastasis and the ability to completely remove the lesion under endoscopy. Early gastric cancer in the following cases generally does not have lymph node metastasis: ① Early gastric cancer with a diameter of <5mm; ② Elevated early gastric cancer with a diameter of <2.5cm; Non-ulceration depressed early gastric cancer with a diameter of <2cm; ④ Mixed early gastric cancer with a diameter of <1.5cm. In the above cases, especially those with better differentiation and shallower infiltration are less likely to metastasize. The indications for endoscopic mucosal resection of early gastric cancer can be considered from the following aspects: ① Mucosal cancer without scars; ② Type I and II early gastric cancer; ③ Early gastric cancer with a diameter of less than 1.5cm. Some early gastric cancers with surgical contraindications or patients who are determined to undergo surgery can also be considered.

(3) Laparoscopic local resection For some early gastric cancers that are not suitable for endoscopic mucosal resection, full-thickness resection of the gastric wall can be performed laparoscopically. Full-thickness resection of the gastric wall at the site of the disease can avoid the pain of surgical gastrectomy. Local lymph nodes can be biopsied under laparoscopy first. If the biopsy shows cancer metastasis, gastrectomy can be performed by laparotomy. Whether to use this technology requires careful consideration.