A cirurgia é o principal tratamento para os diversos estágios do câncer de estômago, sempre que puder ser realizada. Se um paciente se encontra em estágio 0, I, II ou III e com condições físicas suficientes, a cirurgia, muitas vezes junto com outros tratamentos, oferece a única chance real de cura.
A cirurgia pode ser realizada para retirar o tumor e uma parte ou a totalidade do estômago e os gânglios linfáticos, dependendo do tipo e do estadiamento da doença. O cirurgião oncológico tentará preservar o máximo possível do estômago sem doença. Algumas vezes outros órgãos também precisam ser retirados.
A cirurgia é indicada mesmo de forma paliativa, em situações de perfuração do tumor, sangramento com risco iminente de morte ou obstrução do tumor (síndrome pilórica)).
O tipo de cirurgia geralmente depende da parte do estômago envolvida e do comprometimento dos tecidos adjacentes. Diferentes tipos de cirurgia podem ser utilizados para tratar o câncer de estômago, como:
- Ressecção Endoscópica da Mucosa. Este procedimento é realizado apenas para alguns tipos de câncer de estômago em estágio muito inicial, onde a chance de disseminação para os linfonodos é muito pequena. Neste procedimento, o tumor é removido com o auxílio do endoscópio, que é inserido pela garganta até o estômago. Os instrumentos cirúrgicos necessários para retirar o tumor e parte do estômago são introduzidos através do endoscópio.
- Gastrectomia Subtotal. Esta cirurgia é frequentemente indicada se o câncer está localizado na porção inferior do estômago, em algumas circunstâncias pode ser realizada para cânceres que estão apenas na parte superior do estômago. O procedimento consiste em remover apenas uma parte do estômago, A parte restante do estômago é religada com o intestino delgado.
- Gastrectomia Total. Esta cirurgia é realizada quando o câncer se disseminou por todo o estômago. É também indicada se a doença está localizada na parte superior do estômago, próximo do esôfago. Na gastrectomia total, é removido todo o estômago, linfonodos próximos e o omento, podendo incluir, ainda, a remoção do baço e partes do esôfago, intestino, pâncreas e outros órgãos adjacentes. A extremidade do esôfago é então ligada a uma parte do intestino delgado, criando um espaço para o alimento ser armazenado antes de descer para o trato intestinal. Os pacientes que tiveram seu estômago removido só podem ingerir pequenas quantidades de alimento de cada vez, por isso devem comer várias vezes por dia. A maioria das gastrectomias subtotais e totais são realizadas através de uma incisão no abdome, que pode ser subcostal bilateral. Essa cirurgia também pode ser feito por videolaparoscopia.
Sonda de Alimentação
Alguns pacientes têm dificuldade para alimentar-se após a cirurgia do estômago. Muitas vezes, a continuidade do tratamento com quimioterapia e radioterapia pode agravar esse problema. Para ajudar, uma sonda pode ser colocada no intestino através da parede abdominal no momento da gastrectomia. Essa sonda pode ser colocada no ato da cirurgia, ou seja, nos primeiros dias após a cirurgia o paciente se alimenta através da sonda nasoenteral. Alguns pacientes após a cirurgia ao invés de sair com a sonda nasoenteral, realiza uma cirurgia pela parede abdominal, chamada de jejunostomia, em que a sonda é colocada no intestino delgado.
Retirada dos Linfonodos
Em qualquer tipo de gastrectomia total ou subtotal, os linfonodos próximos são removidos. A remoção dos linfonodos é uma parte muito importante da cirurgia. Muitos médicos consideram que o sucesso da cirurgia está diretamente relacionado à forma como os gânglios linfáticos são removidos.
Cirurgia Paliativa para Tumores Irressecáveis
Para pacientes com câncer de estômago inoperáveis, a cirurgia pode ser realizada para controlar a doença e prevenir ou aliviar os sintomas ou outras possíveis complicações:
- Gastrectomia Subtotal. Os pacientes com condições clínicas suficiente para a cirurgia, tem parte do estômago retirada para tratar problemas, como sangramento, dor ou obstrução no estômago, mesmo que não cure a doença. Como o objetivo deste procedimento não é curativo, os linfonodos próximos e partes de outros órgãos normalmente não são removidos.
- Gastrojejusnostomia. Tumores localizados na parte inferior do estômago podem eventualmente crescer o suficiente para bloquear a saída dos alimentos do estômago. Para os pacientes com condições clínicas suficiente para a cirurgia, uma opção para prevenir ou tratar essa obstrução, é contornar a parte inferior do estômago. Isto é feito fixando parte do intestino delgado (jejuno) na parte superior do estômago, permitindo que o alimento saia do estômago por essa nova ligação.
- Ablação Tumoral Endoscópica. No caso de pacientes sem condições clínicas suficientes para a cirurgia, pode ser inserido um endoscópio para guiar um feixe de laser para vaporizar partes do tumor. Isso pode ser feito para parar sangramentos ou aliviar uma obstrução, sem cirurgia.
- Colocação de Cateter. Outra opção de evitar uma obstrução gástrica é a colocação de uma sonda, com auxílio de um endoscópio. Isso manterá a passagem aberta permitindo a saída do alimento. Para tumores localizados na parte superior do estômago, a sonda é colocada na junção do esôfago com o estômago. E para tumores na parte inferior do estômago, a sonda é colocada na junção do estômago com o intestino delgado.
- Posicionamento da Sonda de Alimentação. Alguns pacientes não conseguem se alimentar o suficiente para obter uma nutrição adequada. Nestes casos, uma pequena cirurgia pode ser realizada para colocação da sonda de alimentação na parte distal do estômago ou no intestino delgado, através da pele do abdome. A nutrição líquida poderá ser inserida diretamente pela sonda.
Possíveis Complicações e Efeitos Colaterais
A cirurgia para câncer de estômago é delicada, e podem ocorrer complicações, tais como sangramentos, infecções, fístulas, abcesso, estenoses, e também complicações não diretamente relacionadas com a cirurgia, como infarto, embolia pulmonar e pneumonia.
Você não poderá comer ou beber nada por alguns dias após a gastrectomia total ou subtotal, para dar tempo ao trato digestivo de se restabelecer. Também para o médico se certificar de que não existe vazamentos decorrentes da cirurgia.
Após a recuperação da cirurgia alguns efeitos colaterais podem surgir, como náuseas, azia, dor abdominal e diarreia, especialmente após as refeições. Estes efeitos colaterais resultam do fato de que uma vez que parte ou totalidade do estômago é removida, o alimento entra no intestino muito rapidamente após a ingestão. Esses efeitos colaterais, melhoram com o tempo, mas em alguns pacientes podem perdurar por um longo período. Seu médico pode prescrever medicamentos para aliviar os sintomas desses efeitos colaterais.
Muitas vezes, é necessário fazer alterações na dieta do paciente após a gastrectomia parcial ou total. Mas, a maior mudança é que o paciente terá que fazer refeições menores e mais frequentes. A quantidade de estômago removida afetará o quanto será necessário alterar os hábitos alimentares.
O estômago ajuda o organismo a absorver algumas vitaminas, então se essas partes do estômago foram removidas, o médico prescreverá suplementos vitamínicos.
Antes da cirurgia, pergunte ao cirurgião quanto do estômago ele tem a intenção de remover. Alguns cirurgiões tentam preservar o máximo possível do estômago para permitir aos pacientes uma alimentação o mais normal possível. A desvantagem é que existe mais chances de uma recidiva da doença.
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