Gastric Cancer and Oesophageal Cancer
Cancer is the uncontrolled growth of cells within the body. Usually, all of our cells have a specific lifespan of days to years that is genetically programmed in our DNA. When our DNA becomes damaged, either through the aging process, exposure to toxins such as radiation or chemicals or through inherited genes, some cells do not die a natural death but continue to grow. As they do, they form new cells with the same genetic misinformation. These extra cells may form masses or tumours that can be either malignant or benign. A benign tumour is a tumour that does not invade the surrounding tissue or spread around the body and stays in one place. A malignant tumour can invade the surrounding tissue or spread via the blood or lymph networks and affects other cells and organs.
Oesophageal cancer is becoming a common type of cancer. It used to be most prevalent in southern and eastern Africa and the so-called oesophageal cancer belt of southern Russia and northern China but these geographic borders are rapidly expanding.
Stomach cancer or gastric cancer is the fifth most common cancer type and between 0.75% and 1.9% of the global population develops some form of gastric cancer during their lifetime. Due to the proximity of the top of the stomach with the oesophagus, forms can be combined and are then referred to as gastro-oesophageal junction cancer. This type of cancer is increasing worldwide; however, rates of gastric cancer limited to the stomach are falling due to screening of at risk individuals and increased visits to specialist doctors.
Most gastric cancer is first diagnosed when patients report a feeling of bloating after eating, feeling full after eating small amounts of food, heartburn or indigestion, unexplained weight loss, nausea and abdominal pain to their general practitioner. Those who suffer from gastrointestinal reflux disease or GERD are at particular risk as stomach acid rises into the oesophagus at regular intervals, causing damage to its lining. Also, those who have been diagnosed with a Helicobacter pylori infection are at a higher risk of developing gastric cancer but have less chance of developing oesophageal cancer.
Very early diagnosis usually happens where gastric cancer has run in families or a person suffers from GERD or has been treated for Helicobacter pylori and a decision has been made to undergo regular screening. An existing Helicobacter infection can easily be treated with oral antibiotics.
Treatments for gastric and oesophageal cancer are primarily aimed at tumour removal and preventing further growth, as well as treating the symptoms.
Are there different types of gastric cancer?
There are various forms of gastric cancer and your medical notes may be difficult to understand. Most specific types are based upon the location and type of abnormal cells.
The stomach is split into sections, beginning where it connects to the oesophagus at the oesophageal sphincter at the top of the stomach or cardia. The main sac of the stomach (the stomach body) empties into the duodenum of the small intestine through a muscular ring at the end of the stomach (the pylorus).
Gastric tumours are also described according to the depth in which they have infiltrated the stomach lining. If we imagine the stomach to be a group of bags, one placed inside the other, the innermost bag will represent the gastric mucosa. The second bag that surrounds the mucosa layer is the submucosa; the third represents various thin muscle layers; the fourth the subserosa, and the outermost bag is the final layer that represents the serosa. These five bags only show the inner layer of the stomach and are themselves completely covered by thick layers of muscle that allow the stomach to contract.
In addition, gastric cancer cell types tell us further information about a specific form of cancer. The most common of these are described in more detail below.
Adenocarcinoma
Most gastric cancers are the result of adenocarcinomas that begin within the surface layers of the stomach walls. The word ‘adeno’ refers to glands, in this case usually the mucus-producing glands of the stomach lining. Early stage adenocarcinomas are curable. At later stages, they may metastasize into the surrounding tissues and further afield.
Lymphoma
Gastric lymphoma is a relatively rare type of gastric cancer. The stomach is surrounded by lymph tissue – part of our immune system - and mutated cells can form and multiply in the stomach. Men over 60 years of age are more likely to develop this type of gastric cancer. Unlike many other tumour types, early stage gastric lymphoma is not often treated surgically but responds well to chemotherapy and radiotherapy and, where the cause is Helicobacter pylori, antibiotics. Where the cause is a bacterial infection, antibiotic therapy is enough to put the cancer in remission.
Sarcoma
Sarcomas are growths in connective tissues such as muscle, bone, nerves, cartilage, tendons, blood vessels and fatty or fibrous tissue. A number of these tissue types are constructed from stromal cells.
Some types of sarcoma are benign or not cancerous and small malignant tumours of under 2 cm in size can be removed and the cancer cured. The gastrointestinal stromal tumour or GIST is formed by way of mutations in very specific cell types called interstitial cells of Cajal (ICC). Tumours are more commonly found in the stomach or the small intestine than in the large intestine. Gastric stromal tumours are rarely hereditary and usually begin later on in life; the majority of GIST patients are older than 50 years of age.
If large, sarcomas may first be treated with pharmaceuticals to shrink them. This is ‘targeted therapy’ that targets cancer cells specifically. Surgery is nearly always indicated, and further pharmaceutical treatment is necessary for up to three years post surgery to prevent recurrence.
Gastric carcinoid tumours
Gastric endocrine tumours (GET) or gastric carcinoid tumours are notoriously slow-growing and commonly begin in the digestive tract. Because they grow so slowly they are often detected at a later stage; any symptoms they produce are typically vague, such as diarrhoea and nausea. Occasionally, flushing of the face and neck due to the release of hormones by carcinoid tumour cells occurs. Older women are more likely to develop carcinoid tumours. Treatment is nearly always surgical, especially as most types (Type I and II ECL-cell carcinoid tumours) tend not to metastasize. Type III ECL-carcinoids are more likely to cause the symptoms described in the section above and are more aggressive, often requiring multiple therapies.
Gastrointestinal stromal tumours (GIST)
GIST tumours in the stomach are quite rare and caused by mutations in a very specific cell type. This type of cancer usually develops between the ages of 40 and 70 and can be both benign (non-cancerous) or malignant (cancerous). A positive family history is a risk factor for multiple GIST tumours; without a family history tumours are often singular. Both types can cause skin disorders with raised patches of discoloured skin that can itch.
Are there different types of oesophageal cancer?
The average oesophagus measures 25 cm in length and is a muscular tube that brings food via muscular contractions from the throat to the stomach. When these muscles become stiff or damaged, for example due to the formation of a benign or malignant tumour, swallowing can become difficult.
The oesophagus has two sphincters – upper and lower. The lower sphincter is found at the gastro-oesophageal junction where combination cancer occurs.
When the lower sphincter does not function as it should, stomach acid attacks the insufficiently protected lining of the oesophageal wall leading to an inflammatory disease known as Barrett’s oesophagus. In order to protect itself, this lower part of the oesophagus begins to turn its own cells into ones that mimic stomach cells. The symptom is indigestion and Barrett’s oesophagus is a risk factor for gastro-oesophageal junction cancer.
There are two important types of carcinoma cell types in oesophageal cancer – squamous cell and adenocarcinoma. Of these, squamous cell carcinoma is the most common and can occur anywhere in the oesophagus. Adenocarcinomas are very much linked to Barrett’s oesophagus and occur in the lower section, close to the stomach.
Gastric cancer stages
Your medical notes may have listed a number of codes concerning your diagnosis. Or perhaps you are waiting for further testing and prefer to be well-informed before receiving your results.
The majority of gastroenterologists adhere to the universal TNM staging system. In short, this system uses a scoring system for tumour, (lymph) nodes and metastasis according to biopsy and imaging results.
T stands for tumour. T plus a letter or number describes the size (in centimetres) and location of a tumour. Where more than one tumour is present, the letter ‘m’ (multiple) is added. T letter and number systems for intestinal tumours are:
TX: It is not possible to evaluate the tumour due to a lack of data
T0: No evidence of a primary tumour
Tis: Carcinoma ‘in situ’ with cells only found on the mucosa surface
T1: The tumour is local to the stomach
T1a: The tumour has grown into deeper layers up to the submucosa
T1b: The tumour has grown into the submucosa
T2: The tumour is local to the stomach, has grown through the inner layers and has reached the muscle layer.
T3: The tumour has grown through the muscular layer of the stomach and into surrounding tissues, but not outside of the lining of the abdomen (peritoneum)
T4: The tumour has spread to areas beyond the stomach and surrounding tissues
T4a: the tumour has grown into the peritoneum
T4b: the tumour has grown into organs surrounding the stomach
N stands for nodes or lymph nodes and the following codes apply:
NX: Regional (nearby) lymph nodes cannot be evaluated due to lack of data
N0: No spread to regional lymph nodes
N1: Tumour has spread to 1 to 2 regional lymph nodes
N2: Tumour has spread to 3 to 6 regional lymph nodes
N3: Tumour has spread to 7 or more regional lymph nodes
N3a: Spread to 7 to 15 regional lymph nodes
N3b: Spread to 16 or more regional lymph nodes
Finally, M stands for metastasis. The following codes apply:
M0: There is no spread to distant lymph nodes or other organs
M1: Distant metastasis is present in distant lymph nodes and/or to other organs.
Gastric cancer metastasis is most likely to affect the liver, intestines, lungs, bones, and/or brain.
Gastric cancer is then further grouped according to TNM results in up to 5 stages. Stage 0 is a carcinoma in site and early cancer stage. Stage I (IA or IB) is relatively early non-metastasized gastric cancers with no lymph node spread. Stage II (IIA and IIB) indicates spread limited to the stomach and minimal lymph node spread. Stage III (IIIA and IIIB) indicates multiple lymph node involvement but not spread to organs outside of the peritoneum. Stage IV indicates metastasis.
Oesophageal cancer stages
The oesophagus has less complex layers than the stomach with an inner lining (mucosa), supportive tissue (submucosa) around this, a muscle layer and a final covering membrane (adventitia).
The differences in staging with gastric cancer are relatively few and can be seen below:
T1: The tumour is local to the oesophagus
T1a: The tumour has grown into the mucosa
T1b: The tumour has grown into the submucosa
T2: The tumour has grown into the muscle layer.
T3: The tumour has grown into the adventitia.
T4: The tumour has spread to areas beyond the oesophagus
T4a: the tumour has grown into tissues surrounding other organs (lungs, heart, diaphragm, peritoneum)
T4b: the tumour has grown into other structures (windpipe, spine, major blood vessel)
NX: Regional (nearby) lymph nodes cannot be evaluated due to lack of data
N0: No spread to regional lymph nodes
N1: Tumour has spread to 1 to 2 regional lymph nodes
N2: Tumour has spread to 3 to 6 regional lymph nodes
N3: Tumour has spread to 7 or more regional lymph nodes
M0: There is no spread to distant lymph nodes or other organs
M1: Distant metastasis is present in distant lymph nodes and/or to other organs.
Oesophageal cancer metastasis is most likely to affect the lungs, bones, and/or brain.
What are gastric cancer symptoms?
If you are reading this page, you may have been diagnosed with gastric cancer due to the presence of one or more symptoms.
The most common symptoms of gastric cancer are:
Feeling full after a small meal
Regular episodes of heartburn or indigestion
Loss of appetite and weight loss
Unexplained abdominal pain
Nausea or vomiting
Fatigue
Possible appearance of red blood in the vomit
Possible appearance of dark blood in the stool
There are currently very few national screening programs for the detection of gastric cancer in the general population. Most cases occur after the age of 50 and it is up to the individual to request diagnostic tests and keep their doctor up to date with possible symptoms.
What are oesophageal cancer symptoms?
The symptoms of oesophageal cancer are similar to those of gastric cancer but can include other, more specific signs. You should look out for:
Regular episodes of heartburn or indigestion
Loss of appetite and weight loss
Unexplained chest or back pain
Vomiting soon after eating, with or without blood
Coughing and/or hoarseness
Fatigue
Difficulty swallowing is another symptom of oesophageal cancer but a late one, as by this time the tumour has grown enough to cause the tube to narrow. It is sometimes necessary to place a stent via an endoscopic procedure to keep the oesophagus open if surgical treatment is not an option.
Can I prevent gastric cancer and oesophageal cancer?
Unfortunately, a number of cancer types run in families. If you are aware of a family member suffering from familial adenomatous polyposis (FAP) or hereditary nonpolyposis colon cancer (HNPCC), your risk of developing certain forms of gastric cancer is increased and you should attend annual or biannual screening and be aware of early signs. This also applies to those who have at some point in their lives been diagnosed with a Helicobacter pylori infection, chronic gastric atrophy, gastric polyps, pernicious anaemia or intestinal metaplasia.
Non-familial risk factors include a lack of fibre in the diet and an excess of processed foods and saturated fats.
To prevent oesophageal cancer, one needs to avoid eating very hot food or drinks. Alcohol consumption should be restricted to help prevent oesophageal squamous cell carcinoma. Those with significant belly fat are more likely to suffer from chronic acid reflux, so weight loss can also be a preventive action.
To prevent both types of cancer, you should enjoy regular exercise and get a good night’s sleep as this promotes digestion. Smoking significantly increases risk and this habit should be stopped. You should also avoid highly salted foods, smoked foods and pickled foods. Diets should include daily portions of fresh fruit and vegetables, whole grains, vitamins and minerals. It is suggested that supplementation of vitamins A and C in those who do not consume enough fresh produce can play a protective role.
Certain types of work with continuous exposure to chemicals such as benzene, solvents, herbicides and asbestos can also increase risk. When inhaled through the nose and mouth and swallowed, these hazardous chemicals can attack the cells of the oesophagus and stomach lining and cause mutations in their DNA. Safety equipment such as breathing apparatus and protective clothing should always be used.
Very importantly for the prevention of both types of cancer but especially in the prevention of oesophageal and gastro-oesophageal junction cancer is the treatment of chronic acid reflux and gastro-oesophageal reflux disease. This can be done using prescription or over-the-counter medications, avoiding certain foods (green peppers, onions, chocolate, alcohol, caffeine, fatty foods), sleeping in a partially upright position and refraining from eating at least four hours before going to sleep. Furthermore, surgery can reduce chronic acid reflux if other methods fail. A nissen fundoplication is a safe, laparoscopic procedure that wraps the top portion of the stomach around the bottom of the oesophagus. This means that whenever the stomach contracts, it also seals off the end of the oesophagus and so prevents stomach acids from rising. Even ten years after this type of surgery, most former sufferers remain free of the symptoms of GERD.
How are gastric and oesophageal cancers diagnosed?
If you arrive at your general practitioner’s office complaining of persistent heartburn, nausea, weight loss and fatigue, he or she will probably refer you to a gastroenterologist. This specialist will ask questions about your lifestyle and family history and probably arrange for an upper endoscopy.
Blood tests rarely indicate oesophageal or gastric cancer but might show whether other organs have been affected. Helicobacter infection can be detected by way of a simply breath test.
While it is possible to visualise the stomach with X-rays and CT scans, usually in combination with a barium meal (barium swallow) that coats the linings of these two organs and makes abnormalities easier to observe, many gastroenterologists prefer gastroscopy. During a gastroscopy the doctor inserts a thin, flexible tube with light and camera (endoscope) through the mouth to view the oesophageal and stomach linings in real time. You will probably require sedation for this diagnostic test as the insertion of a tube into the throat can cause retching. If your specialist finds any evidence of unusual growth or discolouration an immediate biopsy can be carried out. Any cancerous cells can then be tested on a molecular level to determine the most successful treatment pathways.
In the case of gastric endocrine tumours, a test known as a Dotatate PET scan is advised. This scan requires some medications to be stopped up to two months beforehand – your GP or our specialist physicians will be able to tell you if this applies to you. For this test, you will be administered a small quantity of radioactive tracer via an intravenous catheter then wait for 45 minutes until this tracer reaches the site of potential cancerous cells. The scan itself takes up to 30 minutes and is carried out in the same way as a regular PET scan.
Depending on the type of cancer that is diagnosed, other tests may be planned. These include blood tests together with CT, PET, MRI or bone density scans that can indicate whether cancer cells have spread into other areas of the body.
Less common diagnostic measures include bronchoscopy to view the airways and check for the possible spread of oesophageal or gastro-oesophageal junction cancer into the respiratory system. Exploratory surgery (laparoscopy) is recommended after imaging shows the presence of gastric cancer and your general surgeon or bariatric surgeon would like to look for further signs of cancer spread without relying on medical imaging, and perhaps combine surgical removal of a tumour with further biopsy.
How is gastric and oesophageal cancer treated?
The most common and recommended treatment for non-metastasized cancer is surgery. Slow-growing tumours in older patients with little to no symptoms may be treated with active surveillance. Active surveillance does not treat the cancer but relies on regular diagnostic tests. If the tumour then begins to show signs of growth or activity, systemic therapies or surgery can be administered.
For early stage gastric cancer and the much rarer cases of early oesophageal cancer detection, non-surgical removal via endoscopy is possible. This is an outpatient procedure that proceeds much in the same way as a diagnostic upper endoscopy.
Surgical treatments for gastric cancer include the removal of some or all of the stomach and perhaps part of the lower oesophagus. These surgeries are called partial gastrectomy, total gastrectomy and gastrectomy with partial oesophagectomy respectively. Oesophageal cancer, when operable, requires partial or total removal of the oesophagus. Where inoperable tumours block the digestive tract above the stomach, non-surgical endoscopic dilation of the oesophagus or the placement of a stent is an option.
As with many types of cancer, surgery alone can be curative. However, both oesophageal cancer and gastric cancer are usually treated with a combination of surgery, chemotherapy, and radiotherapy to lower the risk of recurrence. In both cases, immunotherapy and targeted therapies can be used to slow down the progression of cancer that does not adequately respond to other treatment methods or to target certain cell types on a personalised basis. These treatment methods will be discussed in more detail further on.
Why do I need gastric cancer treatment?
Treatment is always necessary for any type of oesophageal or gastric cancer to try to prevent cancerous cells from travelling to other organs via the many surrounding blood and lymph vessels of these parts of the anatomy. Furthermore, when treated early to mid-stage, gastric cancer can be cured and oesophageal cancer can be kept under control for long periods of time. Even in more advanced stages, new therapies and procedures are continuously increasing longer-term survival.
How do I prepare for gastric cancer treatment? What can I expect?
Approximately 3 to 6 weeks before surgical cancer treatment or other therapy pathways you will be asked to supply the results of your blood tests and copies of any diagnostic and imaging results (gastroscopy, CT, MRI and/or PET). This means we can see how your oesophageal or gastric cancer is progressing and will help us to advise the best treatment options. We will also need any information regarding medication use, other illnesses or disorders and your overall state of health.
You will need to undergo an MRI, PET or CT scan and possibly a bone scan – if these have not yet taken place - which will help us to see if cancer has spread to other organs. If oesophageal or gastric cancer has spread or metastasised you will need to consider both surgical and nonsurgical treatments.
Approximately 2 weeks before your treatment you will need to ask your home doctor to take blood for a preoperative or pre-treatment blood test. Remedazo will inform you well beforehand which tests your doctor will need to take blood for. For some procedures, blood-thinning and other medications will need to be temporarily stopped, others do not. Our or your own doctor will advise you what to do.
Gastric cancer surgery
Please scroll down to the appropriate section. The given information covers all available treatments for gastric cancer, and later for oesophageal cancer, at Remedazo. If you would like information on any treatment not covered in these sections, please do not hesitate to contact us.
Laparoscopic nissen fundoplication
As previously mentioned, one preventive surgery for those suffering from chronic gastric reflux is the laparoscopic nissen fundoplication. A laparoscopic nissen fundoplication is not a cancer treatment but alleviates and often cures gastric reflux – a condition which increases the risk of developing oesophageal cancer. This surgery ties the top of the stomach around the bottom of the oesophagus to prevent acidic stomach contents from damaging the less protected lining of the oesophagus. The stomach contracts when digesting food; in those with chronic reflux, Barrett’s oesophagus or GERD, stomach acid is pushed into the oesophagus, damaging the cells of the oesophageal lining and causing heartburn or indigestion. Damaged cells are more likely to produce abnormal cell forms later on. After a laparoscopic nissen fundoplication, the stomach wrapped around the bottom of the oesophagus also contracts, narrowing the opening into the oesophagus and stopping stomach acid from rising. This procedure is performed by a general or bariatric surgeon under a general anaesthetic and requires a hospital stay of 1 to 2 days.
Endoscopic mucosal resection
For early stage gastric cancer, non-surgical removal of the cancer via endoscopy is possible. This is an outpatient procedure that proceeds much in the same way as a diagnostic upper endoscopy. The gastroenterologist may also carry out biopsies on healthy tissue to check for possible spread. Endoscopic mucosal resection (EMR) is also used to remove gastric polyps and benign growths.
Partial or total gastrectomy
This procedure is carried out where cancer is local to the stomach and is usually a laparoscopic procedure. As the stomach is necessary for digestion, the long-term effects can be serious and mean you are only able to consume small amounts of food at a time. A partial gastrectomy involves the removal of a small part of the stomach; a total gastrectomy removes the stomach and possibly part of the oesophagus, attaching the end of the healthy part of the oesophagus directly to the small intestine. Dietary changes and vitamin B12 supplements are necessary after a total gastrectomy and weight loss can be drastic. Where lymph nodes are affected, a gastrectomy will be paired with a lymphadenectomy procedure that removes the affected nodes. Surgery is not usually recommended for stage IV gastric cancer.
Partial and total gastrectomy procedures are carried out using specialist instruments called trocars and a camera (laparoscopy) or as a robotic assisted procedure. Where previous operations have led to scar tissue, a laparotomy may be necessary. The operation takes place under a general anaesthetic and pain is minimal. Higher pain levels associated with laparotomy are controlled by the placement of an epidural catheter before the procedure begins or with an intravenous pain pump. Laparoscopy requires a hospital stay of between 2 to 4 days and dietary advice must be adhered to. Recovery time varies between 4 to 6 weeks. You will need to take lifelong medication after a total gastrectomy.
Chemotherapy may be necessary if it is suspected that localized cancer has or may spread and is sometimes given before surgery to shrink the tumour. Radiation treatment is also used to kill off potentially remaining cancer cells.
Oesophageal cancer surgery
In general, oesophageal surgeries are more complex than gastric procedures and have more short- and long-term complications. Oesophageal cancer is also less likely to be detected in its early stages. Where early signs are detected, surgery can be curative. Most commonly, oesophageal cancer treatment is a combination of surgery with chemotherapy and radiation therapy. Stage IV oesophageal cancer rarely incorporates surgery into the treatment plan; even so, good results can be obtained.
You will need to follow a liquid diet at least 24 hours before any type of oesophageal surgery. Remedazo will inform you of all pre-operative steps well beforehand. After surgery you will need to sleep with the head end of your bed in a raised position; Remedazo will ensure you have the necessary aids waiting at your chosen accommodation after you have been discharged from hospital.
Endoscopic mucosal resection
For early stage oesophageal cancer, non-surgical removal of the cancer via endoscopy is possible. This procedure proceeds much in the same way as a diagnostic upper endoscopy. You may need to spend a night in hospital as a precautionary measure. The gastroenterologist will also carry out biopsies on healthy tissue to check for possible spread. Endoscopic mucosal resection (EMR) is a low risk procedure, although post-procedural scarring may require further treatment as this can narrow the diameter of the oesophagus and cause difficulty swallowing.
Partial oesophagectomy
During any surgery that removes part of the oesophagus it is important to remove as much potentially affected tissue as possible. The lower oesophagus is located close to the airways, major blood vessels, diaphragm and vagus nerves. Often, these nerves can be damaged and this will affect how your stomach empties after eating. Some procedures integrate vagal-sparing techniques depending on the location of the cancerous tissue. You can ask for more specific information relating to your case during your free Second Opinion.
There are various ways to access the oesophagus. These include the trans hiatal resection (THE) with 4 to 7 cm incisions across the left hand side of the neck and the abdomen, the open Ivor Lewis or transthoracic procedure (TTE) that uses 4 small incisions at the chest and 5 small incisions across the abdomen, the McKeown three incision oesophagectomy using single 4 – 6 cm incisions in the abdomen, thorax and neck, or the minimally invasive Ivor Lewis procedure with five small abdominal incisions and 3 - 4 video-assisted thoracoscopy (VATS) incisions. Cuts above and below the to-be-removed section allow the surgeon to pull out the diseased oesophagus and connect the ends of the remaining healthy tissue.
Usually, a portion of the stomach is pulled up to replace the excised portion of oesophagus; the majority of partial oesophagectomies involve the end closest to the stomach. It is possible that your surgeon will advise removing a portion of the small intestine or colon when the operation site is further away from the stomach or in cases of previous bariatric surgery. All appropriate options can be discussed during your free Remedazo Second Opinion.
Hospital stays of between 4 to 5 days are normal for laparoscopic and thoracoscopic oesophagectomy procedures; thoracoscopic procedures usually require one or two chest drains and both types involve nasogastric tubes to protect the stomach and oesophageal lining from gastric acid and the swallowing of food. Where minimally invasive surgeries are not possible, hospital stays are longer – approximately 7 days.
Additional chemotherapy or radiation treatment is nearly always advised before or after surgery.
Oesophageal-gastrectomy or oesophagogastrectomy
While various surgical techniques are implemented to remove gastroesophageal junction tumours in earlier stage cancer, their outcomes are similar. The majority of surgeries are open procedures and implement the same techniques as described in the previous section.
This surgery type uses the remaining tissue of the stomach to replace the excised portion of the oesophagus. With acid-producing stomach tissue placed higher up, you will need to take antacid medications for life, change your dietary habits and rely on a surgically-placed feeding tube for at least 4 weeks after surgery. This gives the repaired oesophagus time to heal. You will need to remain in hospital for 5 to 7 days and recovery can take anywhere from 6 weeks to 4 months depending on your state of health before surgery and the degree of postoperative weight loss.
Additional chemotherapy or radiation treatment is nearly always advised before or after surgery.
Total oesophagectomy
Total oesophagectomy is often the result of cancer of the throat or pharynx that has affected the upper oesophagus (cervical oesophagus); however, chronic gastrointestinal reflux can cause acid damage and mutation even to the cells of the throat and total resection of the oesophagus is, in these cases, necessary. A total oesophagectomy is a life-changing surgery with many potential complications and will almost always require 3 to 5 pre- and postoperative chemotherapy cycles as well as radiation therapy.
Freeing the entire length of an oesophagus occurs in three stages. Firstly, thoracoscopy helps the surgeon to find important structures that guide the rest of the surgery and allows him or her to separate the part of the oesophagus that runs through the thorax. If a tumour is large, this part of the operation may be carried out as an open thoracotomy.
The second stage is the abdominal stage that further frees the oesophagus from the many surrounding blood vessels and ligaments that keep it in place in the upper abdomen. Finally, the upper section of the oesophagus is freed during the cervical phase by way of an incision in the neck. The entire oesophagus can then be pulled through the abdominal incision. A jejunostomy feeding tube is inserted through the skin of the abdomen into the small intestine allowing you to receive nutrition while unable to eat or drink.
The stomach must then be opened and converted into a tube-like form to replace the oesophagus. In a few cases, part of the small intestine or colon is used. Making a new oesophagus out of a similar hollow organ is known as interposition. The incisions used for the abdominal stage can be used for gastric or small intestine interposition but colon interposition may require additional incisions. During surgery, a tube is placed via the nostril that opens into the small intestine allowing fluids to be removed via suction. You will not be able to eat until given the go ahead by your surgeon – be prepared to avoid food and drink for up to 3 weeks after the procedure; you will have to depend on the jejunostomy for all of your nutritional requirements.
Peri-operative oesophageal and gastric cancer scare
All oesophageal and gastric cancer surgeries require you to drink an oral gastric preparation before surgery. Gastric surgeries include the insertion of a drain through an abdominal incision to remove fluids from the operation site. This drain will remain in place for 24 to 48 hours after surgery. On the whole, partial and total oesophageal surgeries include thoracic drains (chest tubes) that remain in place for at least 3 days, as will the nasogastric tube.
For all of these surgery types, you will be admitted to your chosen clinic on the day of the procedure. Certain people such as those with a very high BMI, breathing difficulties, diabetes or other chronic illnesses usually benefit from spending the night before the operation in a hospital setting. This also applies to those requiring total oesophagectomy or those who do not want to drink the oral gastric preparation in a home setting.
From midnight of the day before your surgery, you will be asked to refrain from eating. Undigested stomach contents can create serious complications during general anaesthesia. Smokers should stop smoking at least one week before oesophageal surgeries as thoracic incisions will affect breathing quality; stopping smoking beforehand also improves oxygen levels throughout the body. Between midnight and six hours before anaesthesia you may only drink water or clear liquids. You are not permitted to eat, drink or smoke in the six hours preceding anaesthesia. Failure to comply may mean the anaesthesiologist and surgeon will be forced to postpone your procedure. This is purely for your own safety. It is possible to brush your teeth during this period but no water may be swallowed. In certain circumstances, medical staff will administer oral medications with a little water. This is administered under the advice of the anaesthesiologist and is therefore permitted.
Approximately sixty minutes before the planned procedure time you will be collected from your room and brought to the surgical department either in your bed, on a gurney, in a wheelchair or on foot.
Preoperative gastric cancer surgery preparation requires:
An intravenous line
A blood pressure cuff placed on the upper arm
The completely painless placement of electrodes to the chest to measure heart activity
A finger or ear sensor to measure oxygen levels in the blood
A general anaesthetic
Preoperative oesophageal surgeries will further require:
A urinary catheter (usually placed after you are anaesthetised)
An epidural catheter or a second intravenous line for postoperative pain control
An arterial catheter
A double lumen endotracheal tube for one-lung ventilation during thoracic surgery
At the surgeon’s signal, you will be anaesthetised.
What happens after oesophageal or gastric cancer surgery? What can I expect?
You will be woken by the anaesthesiologist immediately after surgery and transported from the operating theatre to the recovery room. Here you will be carefully monitored. All patients remain in the recovery ward until they are fully responsive and any pain is well under control.
When the anaesthesiologist is satisfied you are fully awake and comfortable you will be brought to a surgical ward; total oesophageal patients will be taken to the medium care unit where they will remain for 24 to 72 hours before being transferred to a general surgical ward. Pain medication is given as standard for the first 48-hours and then upon request and according to your personal doctor’s prescription. Thoracic surgeries are often painful and you will be able to take advantage of an epidural pain pump or intravenous pain pump and administer your own pain medication. You will not be permitted to lay flat as this can cause serious complications after oesophageal surgery.
Arterial lines are removed within 24-hours after surgery; those in medium care units retain the arterial line until transfer to a general surgical ward. A single intravenous catheter will continue to administer fluids for at least 24 hours and your abdominal drain will be removed by a trained nurse or doctor within 2 - 3 days, depending on the complexity of your operation. Urinary catheters are usually removed after 24-hours.
All oesophageal procedures require a nasogastric tube that gives your oesophagus the opportunity to heal, as well as a feeding tube (jejunostomy) that provides nutrition directly into the small intestine until you are able to swallow. Chest tubes remain in place for 4 days, as will the nasogastric tube. Breathing exercises under the guidance of a physical therapist are extremely helpful when recovering from any type of thoracic surgery. Remedazo ensures you are supported by a complete, multidisciplinary team during your hospital stay and will arrange all home visits and follow ups during your time at your chosen accommodation.
The majority of gastric cancer patients are out of bed within 8 hours of exiting the recovery room. For total oesophageal procedures this period of time may extend until you are taken to the general surgical ward. Upon discharge from hospital you will be transported to your accommodation and supported by your personal Remedazo team until you have safely and comfortably returned home or have completed further treatment. You will be able to travel within 2 to 4 days after discharge from hospital after laparoscopy without thoracoscopy. For those who have undergone thoracoscopy, this time should be lengthened to 4 to 7 days. You will need to wear compression stockings and preferably split long flights into shorter journeys after all types of gastric and oesophageal surgery.
Long-term postoperative care includes the removal of stitches after 5 to 14 days. This can be done by your general practitioner at home if you are not attending further treatment sessions. While full recovery from gastric operations and video-assisted partial oesophagectomy only requires 3 to 4 weeks, total oesophagectomy and open partial surgeries may need up to 3 to 4 months of rest and rehabilitation.
Benefits of oesophageal and gastric cancer surgery
Both oesophageal and gastric cancer surgeries aim to remove a tumour in its entirety and so have the potential to be curative procedures. Surgery is nearly always recommended in cases of non-metastatic cancers; however, most treatment pathways integrate multiple therapies. In the case of gastric and oesophageal cancer, these are most commonly chemotherapy and radiotherapy. Aftercare involves sometimes significant dietary changes and nutritional supplementation, pharmaceutical replacement of digestive hormones in total and some partial gastrectomy procedures, and a temporary - occasionally permanent - jejunostomy for more complex oesophageal surgeries.
Disadvantages of oesophageal and gastric cancer surgery
Postoperative infection is always a risk with this type of surgery and patients are administered antibiotics as a preventive measure before surgery commences. Due to the high levels of bacteria in the digestive tract, seepage can occur into the thoracic or abdominal cavities with serious consequences. Your chosen clinic’s doctors and nurses are trained to recognise the symptoms of infection very early on and various steps are taken to protect inner sutures and give internal incisions the opportunity to heal. Other short-term risks include bleeding, adverse reactions to the anaesthesia, blood clots, an urge to urinate in the presence of a urinary catheter, and breathing problems - the latter of these is common in thoracic procedures. Avoidance of cigarettes and breathing exercises prior to thoracic surgery can significantly shorten recovery times. Oesophageal surgeries with thoracoscopy or open thoracotomy incisions are linked to high levels of pain, for which epidural or intravenous patient-controlled pain pumps are prescribed as standard.
Long-term complications include the inability to absorb certain nutrients from your food or produce enough of certain hormones or enzymes necessary for digestion. Scar tissue formation may increase your risk of oesophageal obstruction. Dumping syndrome, where food exits the stomach at a rapid rate, may occur. Furthermore, swallowing can be difficult in the months after oesophageal surgery. More complex procedures require lifetime medication and nutritional supplements. We recommend you visit your local gastroenterologist early on so he or she can keep an eye on your progress.
Nonsurgical treatments for gastric cancer and oesophageal cancer
Nonsurgical treatments are offered to those unable to undergo surgery due to low overall levels of health or those who need to keep metastatic or potentially recurring intestinal cancer under control. These treatments include radiofrequency ablation of the tumour that destroys cancer cells using electrical current, and microwave ablation which uses needles that emit microwaves to produce localised heat. Target cells are accessed by way of needles and these procedures are carried out under sedation and with a local anaesthetic together with medical imaging machines. It is possible that you will need to stay overnight. Another option is cryotherapy where, instead of electricity, low temperatures are applied directly to a tumour to freeze and kill the cancerous cells.
Non-surgical neo-adjunct and adjunct therapies for gastric and oesophageal cancer
As already mentioned, additional therapies are often advised before or after surgery to either shrink a tumour before resection or to destroy potentially remaining cancer cells that may have been missed during a surgical procedure. The most common of these non-surgical treatments is chemotherapy but there are a number of options, all of which contribute to cancer control in all stages of the disease.
Gastric and oesophageal cancer chemotherapy
Gastric cancer is most often treated with surgery in combination with chemotherapy, as is oesophageal cancer. Squamous cell carcinomas tend to respond less positively than adenocarcinomas in oesophageal cancer but are not completely resistant. Chemotherapy may be given to shrink tumours prior to surgery, to treat cancer types with the potential to return, and also to destroy any cancer cells that may have been left behind after surgery. Where surgery is not indicated, chemotherapy is a primary treatment usually supported by other non-surgical therapies, most of them listed within this section. Chemotherapy drugs are often given in combination such as FLOT - fluorouracil, folinic acid, oxaliplatin and docetaxel. Multiple cytotoxic (cell-toxic) combinations exist, all of which can be discussed with a Remedazo oncology specialist.
Chemotherapy drugs are administered intravenously via a portacath, PICC line or central venous catheter. Drug cycles usually last for 21 days and, depending on your type of cancer, may be repeated up to 6 times. This can mean 5 months of therapy with regular blood tests and follow ups of symptoms and side effects. Ask Remedazo for more information regarding longer-term stays where all of your physical, psychological and emotional needs are catered for during this stressful time. Alternatively, we can arrange similar accommodation and familiar, trusted team members for regular returns to your clinic of choice and cater for your accompanying family members or friends.
Gastric and oesophageal radiation therapy
Radiotherapy may be given before surgery to shrink a larger tumour (neo-adjuvant radiotherapy), after surgery to reduce the risk of the cancer recurring (adjuvant radiotherapy) or as a palliative measure for advanced cancers to help control uncomfortable symptoms such as narrowing of the oesophagus.
Radiotherapy as a stand-alone cancer therapy is rare but newer radical chemo-radiotherapy combinations of approximately 25 daily treatments given over the course of 5 weeks has been known to cure both cancer types, significantly shrink tumours or decelerate tumour growth.
Fractionated external beam radiation therapy (EBTR) may be given to prevent the growth of potentially remaining cancer cells after surgery. This therapy is given over the course of 3 to 7 weeks in low doses. More recently, stereotactic body radiation therapy (SBRT) has provided patients with a higher dose, shorter course of radiation therapy.
Radiotherapy for oesophageal and gastric cancer is composed of two main types – external beam radiation therapy (EBRT) and stereotactic body radiation. If cancer has spread to the bone tissue (bone metastasis), patients may be offered radiopharmaceuticals. These are injected drugs that contain radioactive substances that settle in areas of damaged bone. Here, they emit radiation that kills cancer cells. These drugs also relieve bone pain caused by metastasis and can extend life.
External beam radiation therapy focuses beams of radiation into the affected area of oesophagus or stomach and requires short (10 to 30 minute) visits to the hospital 5 times a week for several weeks. Long-term stays with all accommodation, home nursing care, catering, transportation and follow ups can be seamlessly arranged by your Remedazo team.
EBRT is a painless treatment and recent technology now enables oncologists to be even more precise with dosage and range. Additional options such as three-dimensional conformal radiation therapy or 3D-CRT use computers to map the area that requires treatment and shape the radiation beams to avoid damaging non-cancerous tissues. The even more advanced intensity modulated radiation therapy (IMRT) machine moves around the patient, shapes the beams and adjusts radiation intensities. This may be done with built-in scanners (image guided radiation therapy or IGRT) or using a more rapid but not necessarily more effective technique called volumetric modulated arc therapy or VMAT. You will be able to discuss all of these alternatives with a Remedazo oncology specialist.
The side effects of radiation therapy often depend on its effects upon healthy tissues that are found close to the oesophagus and stomach including the major blood vessels, airway, thyroid gland, heart, diaphragm, liver, gall bladder and intestines. In addition, radiation treatments can make you feel tired for weeks to months. At Remedazo, all associated information will be given upon or shortly after your consultation; you can then make an informed decision regarding the types of radiotherapy available to you.
Oesophageal and gastric cancer immunotherapy
Checkpoint inhibitors allow your immune system to respond to the presence of specific cancer cells and attack them. This response is often absent during tumour growth. It has been shown that some advanced gastric and oesophageal cancers respond well to immunotherapy treatment but this certainly does not apply to all. Ask about immunotherapy options during your free Second Opinion.
Drugs such as pembrolizumab block the activity of a protein that prevents your immune cells from recognizing and attacking inflamed tissues and cancer cells. Vantictumab – a human monoclonal antibody that is part of the immunotherapy classification - has recently been approved for the treatment of gastric cancer and stops cancerous gastric cells from dividing. Oncologists partnered with Remedazo are renowned for their knowledge of the most recent clinical studies and research pertaining to effective and new cancer-fighting drugs.
Each intravenous immunotherapy treatment requires at least a 2-hour stay in a clinical setting and should be repeated every 2 to 3 weeks. Immunotherapy has been shown to increase survival times in metastasised cancer; however, immunotherapy is rarely offered before other types of therapy. The usual first-line treatment for metastatic oesophageal or gastric cancer without surgery is chemotherapy plus targeted therapy.
The side effects of immunotherapy are many and can be serious. Those offered this type of treatment are given in-depth information regarding side effects and the detection of their early signs. Remedazo can put you in touch with one of our specialist oncologists to discuss your eligibility for immunotherapy based upon your personal medical history.
Gastric and oesophageal cancer pharmaceuticals
Tyrosine kinase inhibitors (TKIs) in combination with checkpoint inhibitors (immunotherapy) have been proven to be effective in the treatment of metastatic gastric cancer; however, not every type of gastric cancer responds in the same way to either inhibitory drugs or immunotherapy. Tyrosine kinase inhibitors are drugs that prevent the growth of a tumour’s own blood supply network and are sometimes combined with early treatment modalities such as gastrectomy. These drugs either alone or in combination with other treatments have achieved breakthrough advances in the management of a number of hard-to-treat malignancies, including advanced cases of gastric and oesophageal cancer.
Gastric and oesophageal cancer cryotherapy
Cryotherapy uses cold temperatures to freeze cancerous cells. This can be a first-line treatment with very small, localised tumours where a patient is unable to undergo surgery.
Multiple cryotherapy procedures may be required if cancer cells are left behind. Cryotherapy or cryoablation of the oesophagus and/or stomach is performed under an endoscopic procedure that only requires a little sedation and is an outpatient procedure, although in the case of larger tumours or oesophageal treatment a night or two in hospital may be advised. Using a laparoscopic camera, the gastroenterologist locates the area where an earlier biopsy has shown that cancer is present and inserts hollow needles through which an extremely cold gas is passed. These extremely low temperatures freeze and kill the cancer cells.
Gastric and oesophageal cancer alternatives
It is possible that you have been given a choice of one or more alternative treatments or have not yet made an appointment for your free e-consult and are simply browsing the possibilities.
The accepted and current gastric and oesophageal cancer treatment alternatives have been described in detail above. Recent advances mean that some stage IV oesophageal cancers can go into complete remission for well over 5 years. Complementary gastric cancer remedies are unproven and should not take the place of accepted treatment courses. Cancer stem cell therapies for gastric and oesophageal cancer are, as yet, insufficiently developed to be used as first-line treatment.
Of course, there is no alternative for professional medical advice. Please call us to arrange your e-consult and the opportunity to speak personally with specialist gastroenterologists, bariatric surgeons, thoracic surgeons and oncologists to determine the best treatment type for you. You can discuss all oesophageal and gastric cancer treatment alternatives with them, ask for second or third opinions, and take the first step towards your personalised Remedazo holistic care package.
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