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SURGICAL SPECIALISTS, P.C.

STOMACH CANCER

The stomach is part of the digestive system. It is a muscular sac
located at the top of the abdomen, just below the ribs, between
the chest and the hips.
After food is chewed and swallowed, it moves
from the mouth through the esophagus, and into the stomach. Once in
the stomach, the food mixes with gastric juice to begin the digestive
process. The muscles within the stomach then push the liquid into the
small intestine.

The stomach is part of
the bowel between
the esophagus above,
and the small bowel
below. Tumors in the
stomach may involve
removing part of the
stomach

Another term for stomach cancer is gastric cancer. It is a malignant
tumor that forms in the tissues in the lining of the stomach.
The
cancer can start in any section of the stomach. Symptoms, treatment
options and survival outlook depend on the location of the cancer in the
stomach.

The wall of the stomach consists of five layers. As the cancer grows
deeper into the wall the outlook diminishes. The cancer can spread over
time, deeper into the stomach wall. A stomach tumor can eventually grow
through the stomach's outer layer and extend into other organs such as the
pancreas, esophagus, liver, and intestine. lungs and lymph nodes. The distant
spread of cancer is called metastasis. The five layers of the stomach,
starting from the inside out are:

  • Mucosa – This is the innermost layer and where most stomach
    cancers begin. The juices produced by the glands in this inner layer
    help digest food.
  • Submucosa – This is the next layer and the support tissue for the
    inner layer.
  • Muscularis – This layer of muscle moves and mixes the contents
    of the stomach.
  • Subserosa – This layer is the support tissue for the outer layer.
  • Serosa – This outermost layer acts as a wrapping for the stomach.

Stomach cancer can develop in any part of the stomach and is
typically develops slowly over several years.
Pre-cancerous changes
occur in the lining of the stomach before a cancer develops. These early
changes rarely cause symptoms and it is for that reason that stomach
cancer is rarely detected in the early stages.

While stomach cancer is common worldwide, it is uncommon in the United
States. Over the past 60 years there has been a significant decrease in the
number of people diagnosed with this and the numbers continue to decline.
This is mainly attributed to the fact that people in this country are eating
less salted, cured and smoked food and the increased use of refrigeration
for food storage. Some doctors also attribute the decline in stomach cancers
in the United States to the use of antibiotics to treat infections. These
antibiotics kill the H. Pylori bacteria which may be a major cause of stomach
cancer. When diagnosed and treated in its early stage, stomach cancer can
often be cured. If it is in a more advanced stage when it is discovered the
outlook can become less favorable.

The cancers are classified according to the type of tissue from
which they originate.
When the term stomach cancer is used it is
generally referring to adenocancarcinoma since the other forms are
stomach cancer are rare.

The different types of stomach cancer include:

  • Adenocancarcinoma - This is the most common form of stomach
    cancer and it accounts for 90% to 95% of the cases. This cancer
    starts in the glandular tissue of the stomach in the cells that the
    innermost lining.
  • Lymphoma – This stomach cancer involves the lymphatic system
    and is a rare form of the disease. The walls of the stomach contain
    a few immune system cells that can develop cancer.
  • Carcinoid Cancer – This is a rare form of stomach cancer that
    develops in hormone producing cells.
  • Gastrointestinal Stromal Tumor (GIST) – GIST is also a rare
    form of stomach cancer that begins in specific nervous system cells
    that are found in the stomach.

Cancer begins in cells that are the building blocks that make up
tissues.
Tissues then make up the various organs in the body. When the
body requires it, new cells are formed as normal cells grow and divide.
When normal cells get old or damaged, they will die, and new cells will take
their place. There are times when the process goes wrong. New cells may
form when the body doesn't require them, and old and damaged cells will
not die, as they should. A mass of tissue called a growth (nodule or tumor)
is formed as a result of the buildup of these extra cells. These growths can
be benign or malignant.

Stomach cancer can spread to other parts of the body by invading other
tissues, shedding cancer cells into the abdomen or spreading to other
organs.

  • Invading – When a malignant stomach tumor grows it can invade
    organs adjacent to the stomach.
  • Shedding – Cancer cells can break off (shed) from the original
    stomach tumor. New tumors may then form on the surface of nearby
    organs and tissues as the cells shed into the abdomen.
  • Spreading – When cancer cells break away from the original tumor
    they can spread to other organs in the body through the blood
    vessels. These cancer cells can also spread through lymph vessels to
    nearby lymph nodes. The cells may attach to other tissues and grow
    to form new tumors that could damage the tissues they attached to.
RISK FACTORS

The causes of stomach cancer are still largely unknown. However,
it has been found that individuals predisposed to certain factors,
will more likely develop stomach cancer than those without them.

Most people who have the increased risk factors do not develop stomach
cancer. However, there are some patients who develop stomach cancer
without having any of the increased risks.

The following are potential risk factors, some of which can be controlled,
that may contribute to the potential development of stomach cancer:

  • Long-term inflammation of the stomach Conditions
    associated with long-term inflammation of the stomach
    increases the risk of stomach cancer.
    Pernicious anemia is a
    blood disease that can contribute to stomach inflammation.
    Long-term stomach inflammation can also result from having had
    part of the stomach removed. Over a period of years the risk for
    stomach cancer can increase after the removal because the patient
    may experience long-term stomach inflammation.
  • Helicobacter Pylori Infection A bacterium known as
    H. Pylori commonly affects the mucosa (inner lining) of the
    stomach and appears to be a major cause of stomach cancer.

    This can lead to inflammation of the stomach and peptic ulcers.
    This bacteria is also linked to some types of stomach lymphoma.
    However, few people affected with the bacteria do develop stomach
    cancer. Simple treatment can include antibiotic therapy and blood
    test or endoscopy to confirm successful treatment
  • Some Types of Stomach Polyps Polyps are small mushroom
    like growths on the lining of the stomach.
    Most polyps do not
    increase the risk of stomach cancer. Adenomatous polyps or
    adenomas can sometimes develop into stomach cancer.
  • Family History – If there is a history of several close relatives
    having stomach cancer then the risk of developing the disease can
    increase for other family members.
  • Smoking – Smokers, especially heavy smokers, are more apt to
    develop stomach cancer than non-smokers and are at a higher risk
    of developing other cancers as well.
  • Alcohol – Alcohol consumption increases the risk of developing
    stomach cancer in addition to other cancers.
  • Obesity – Obesity presents a risk of cancer developing in the upper
    part of the stomach.
  • Poor Diet – A diet high in smoked foods, salted fish and meat and
    pickled vegetables increases the risk for stomach cancer. A diet high
    in fresh vegetables and fruits may decrease the risk for stomach
    cancer.
  • Lack of Physical Activity – This can become a cause for an
    increased risk in developing stomach cancer.
  • Male Predominance – There is a higher incidence in male patients
    with a ration of one to three compared to female patients.
  • Ethnicity – Stomach cancer is more common in the United States
    in Hispanic Americans and African Americans than in non-Hispanic
    Whites.
  • Advanced Age – Patients have an average age of 70 for men 74
    for women at the time of diagnosis.
  • Prior stomach surgery – Patients who have had part of their
    stomach removed to treat other problems like ulcers seem more
    susceptible to developing stomach cancer.
  • Menetrier Disease – This is a rare disease that includes changes
    in the stomach lining and may be considered as a risk of stomach
    cancer.
  • Type A Bloo – People with type A blood have a higher risk of
    developing stomach cancer. The reason is unknown.
  • Epstein-Barr Virus – This virus has been found in the stomach
    cancers of some patients. It is a virus that causes infectious
    mononucleosis. It hasn't been confirmed that it is a cause of
    stomach cancer, but its presence has been found on occasions
    when the cancer exists.
  • Workers in Certain Industries – People working in coal mining,
    nickel refining, rubber and timber processing industries are at a
    higher risk.
  • Asbestos – Workers exposed to asbestos fibers are at a higher risk.
SYMPTOMS

Stomach cancer usually does not display any symptoms in its early
stages. As the cancer grows symptoms begin to develop. By the
time the symptoms have developed, the cancer is usually in an
advanced stage.
However, symptoms from stomach cancer are very often
indicative of other health issues unrelated to stomach cancer. Your doctor
should be advised of these symptoms when they are present. If there is
stomach cancer, it will be more susceptible to being treated successfully.
The symptoms at different stages of the cancer include:

Early Stage Symptoms -
  • Indigestion or a burning sensation (heartburn)
  • Appetite loss
  • Pain or discomfort in the area of the abdomen
Middle Stage Symptoms –
  • Feeling bloated or full after having a small meal
  • Weakness and fatigue
Late Stage Symptoms –
  • Difficulty swallowing
  • Weight loss
  • Nausea and vomiting
  • Vomiting blood
  • Blood in the stool
  • Pain in the upper abdomen
  • Diarrhea or constipation
TESTS AND DIAGNOSIS

In addition to discussing your family history and ordering some blood or lab tests, the following tests may be ordered to determine the presence of stomach cancer:

  • Physical Examination – The abdomen is felt to check for changes
    in the area as well as for fluid and swelling. The examination of
    lymph for swelling is also performed. Abdominal lumps can be found
    during a rectal examination.
  • Upper GI Series – This test requires the patient to drink a barium
    solution and then x-rays are taken of the stomach, esophagus, and
    the first part of the intestine. The barium outlines the stomach in
    the x-ray. This enables the doctor to find tumors or other abnormal
    areas with the use of special imaging equipment.
  • Endoscopy – An endoscope (thin lighted tube) is passed through
    the mouth and esophagus into the stomach. This enables the doctor
    to view the stomach. Prior to the procedure the throat is numbed
    with an anesthetic spray and drugs are used to sedate the patient.
  • Biopsy – A biopsy is the only way to detect the presence of cancer
    cells with certainty. The endoscope has a tool for removing tissue
    from the stomach for a biopsy. The endoscopic procedure is
    described above. The tissue samples are studied by a pathologist
    under a microscope to determine the presence of cancer cells.
TREATMENT

Unless stomach cancer is diagnosed at an early stage, before it has
spread, it is difficult to cure.
The difficulty with finding it at the early
stage, is that early stomach cancer has few symptoms. When the disease is
diagnosed it is most often in an advanced stage. Advanced stomach cancer
can be treated and the symptoms can be relieved.

Several factors determine the treatment that will be selected to manage the
stomach cancer. They include the stage of the cancer, as well as the size
and location of the tumor. The patient's age, overall health and personal
preferences are also considered when developing a treatment plan. The
primary goal is to eliminate the cancer when possible. If that is not an
option then the goal is to prevent the cancer from growing and spreading.
When treatments aren't an option because the cancer is advanced and the
treatments will not offer any benefits, other means may then be suggested
to relieve the symptoms and help make the patient as comfortable as possible.

SURGERY
The location, type and stage of the cancer are the determining
factors for the type of surgery that will be required.
The entire
stomach may be removed or just the part that is affected by the
cancer. The goal of surgery is to remove all of the stomach cancer and
a portion of healthy tissue. There are risks associated with including
the risk of infection and bleeding. Digestive problems may arise when
all or part of the stomach is removed. The surgical options available
include:

Removing early stage tumors from the stomach lining -
If the cancers are very small and limited to the inside lining of
the stomach, they may be removed with the use of an endoscope
in a procedure known as endoscopic mucosal resection. The
endoscope, a lighted tube with a camera, is passed down the
throat into the stomach. Special instruments are used to remove
the cancer and a portion of healthy tissue from the stomach
lining.

Partial (Subtotal) gastrectomy - This procedure is performed
when tumors are located at the lower part of the stomach close
to the intestines. The part of the stomach with the cancer is
removed. There are times when part of the esophagus and the
first part of the small intestine is also removed. The remaining
part of the stomach is attached to the intestine. Lymph nodes
and tissue located nearby may also be removed.

Total gastrectomy - This procedure is performed for tumors
located at the upper part of the stomach, or if the cancer has
spread throughout the stomach. The complete stomach, parts
of the esophagus and small intestine, lymph nodes and other
tissues near the tumor are all removed. A portion of the pancreas
may also have to be removed. There are rare instances when
the spleen also has to be removed. The remaining part of the
esophagus is then directly attached to the small intestine.
Removing lymph nodes in the search for cancer –
The surgeon may remove lymph nodes when partial or total
gastrectomies are performed to make sure the cancer has not
spread.

Surgery to relieve symptoms and signs of stomach cancer
In cases where surgery is unable to cure the cancer, it can serve
as a means to make the patient more comfortable. When part of
the stomach is removed in people with advanced stomach cancer,
the surgery may relieve the symptoms and discomfort associated
with the growing tumor. This is known as palliative surgery.

Cancer that blocks the digestive tract – When stomach cancer
is in an advanced stage, a tumor may form that will block the
passage of food through the digestive tract. This is treatable with:

  • Radiation – This can possibly help shrink the tumor that
    is creating the blockage to the intestine.
  • Stent – An endoscope is used to place a stent in the
    intestine. The stent is a tube made of metal mesh or
    plastic. Food and liquid can pass through the center of
    the tube and essentially bypass the tumor.
  • Laser – An endoscope is used to place a laser in the
    digestive tract. The laser is a concentrated beam of
    intense light that generates heat and kills tissue with
    the heat. The cancer cells blocking the digestive tract
    are destroyed with the laser, and the obstruction is
    relieved.

The hospital stay for these procedures may extend to a week
or more. The healing process is different for each individual.
Medicine will help control the pain that may be experienced the
first few days after the surgery. Aplan for the relief of pain is
discussed prior to the surgery and it can be adjusted as needed.
The patient may feel tired and weak for a period after the surgery
and will have to be monitored for indications of infection,
bleeding or other issues that will require some form of treatment.

CHEMOTHERAPY
Chemotherapy is given to most patients who have stomach
cancer.
Unfortunately, stomach cancer has not been particularly
sensitive to chemotherapy. But the treatment usually does reduce
the size of the tumor, relieve symptoms and increase survival time.
Chemotherapy is usually given in an outpatient setting at the hospital
or doctor's office. However, some people do have to stay in the
hospital while receiving the treatment.

Chemotherapy is a treatment where medications are used to
attack and kill cancer cells.
These drugs travel in the blood stream
throughout the body and kill cancer cells that may have gone beyond
the stomach. A combination of medications is calculated by an
oncologist based on staging and a patient's overall health. The
chemotherapy is usually administered intravenously and given at
specific time intervals, determined by the oncologist, who works
with the surgeon on the overall treatment plan for the patient.

Chemotherapy may be used before surgery to shrink the tumor
so that it becomes easier to remove surgically.
It can also be
used after surgery to kill any cancer cells that may have remained in
the body.

Radiation treatments are often used in combination with
surgery and chemotherapy.
When stomach cancer cannot be
treated surgically, radiation is often used in combination with
chemotherapy to treat the cancer. It is sometimes used alone to
help relieve symptoms in people with advanced stomach cancer,
such as swelling and obstruction.

RADIATION THERAPY
High-energy beams are used to kill cancer cells, shrink them,
or damage them and keep them from growing.
The radiation
comes from a machine that aims radiation beams at the cancer in the
abdomen. It affects only those cells in the part of the body that is
being treated. Radiation can kill very small areas of cancer that cannot
be seen and removed during surgery. It is generally given in a hospital
or clinic five days a week, for several weeks.

Radiation may be used before surgery to shrink the tumor so
that it becomes easier to remove surgically.
It can also be used
after surgery to kill any cancer cells that may have remained in the
stomach area.

Radiation treatments are often used in combination with
surgery and chemotherapy.
When combined with chemotherapy
after surgery, radiation can often delay or prevent recurrence of the
cancer. It may also help prolong the life of the patient. When stomach
cancer cannot be treated surgically, radiation is often used in
combination with chemotherapy to treat the cancer. It is used to
relieve the pain, bleeding and eating problems by shrinking the tumor.

TARGETED CHEMOTHERAPY
Medications used to attack specific abnormalities within cancer
cells are considered targeted therapy.
Trastuzumab (Herceptin®)
is a man made version of an immune system protein. It is know as a
monoclonal antibody and is used more often to treat breast cancer.
Recent studies show that when given with chemotherapy it helped
some patients with metastatic stomach cancer live longer compared
to cases where chemotherapy was given alone. This drug is only
helpful for the stomach cancers that contain a certain type of protein.
The FDA has now approved it as part of the treatment for stomach
cancer. There are drugs that are used to treat gastrointestinal
stomach cancer which is a rare form of cancer. Imatinib (Gleevec)
and sunitinib (Sutent) are two such medications.

NUTRITION
Food intake is an essential ingredient in the treatment of
stomach cancer.
Proper nutrition is fundamental to maintaining
strength and healing. Having stomach cancer may make it difficult
to eat. With the aid of the medical team and a nutritionist, a diet plan
will help meet the needs of the patient. It is important to ingest the
necessary amount of vitamins, proteins, calories and minerals the
patient. This will help the patient prevent weight loss and discomfort
when eating. There are cases where the intake of the required
nutrition is assisted with the help of an IV (intravenous). Daily
supplements of vitamins and minerals may be necessary after
surgery. These include calcium, iron, vitamin D and vitamin D shots.

CLINICAL TRIALS

Studies used to test new forms of treatments are called clinical trials.
They may include new surgical approaches, new approaches to radiation,
testing new chemotherapy drugs, or even new methods such as gene therapy.
These studies can lead to new methods becoming part of the standard
treatment for the cancer when their results indicate safety and effectiveness.

Clinical trials offer access to treatments that aren't ordinarily
available.
While they may produce serious unexpected side effects, they
may provide positive results that would not have been received with the
normally approved standard treatments. Clinical trials are closely monitored
by the federal government to ensure safety for the patients participating in
the trials.

PREVENTION

While there are no specific known reasons for the cause of stomach
cancer, there are known risks for it.
The risks can be reduced by some
lifestyle changes that include:

  • Reduce the amount of salty and smoked foods that are eaten.
  • Eat a substantial amount of fruits and vegetables.
  • Don't smoke.
  • Weight control.
  • Consult your doctor about your risks of getting stomach
    cancer – Some medical conditions as we stated in the risk section,
    do increase the risk for stomach cancer. If you get diagnosed with
    any of those conditions, you should discuss the method of closely
    monitoring those conditions with your doctor. This may include
    periodic endoscopies. The benefits of undergoing periodic testing
    may far outweigh the risks of not doing so.
  • Surgery – Hereditary diffuse gastric cancer syndrome is a cause for
    a small percentage of stomach cancers. People who have that gene
    may decide to remove the stomach before the cancer develops. Most
    people with the gene do eventually develop stomach cancer. If there
    is a strong history of stomach cancer in the family surgery should
    be discussed with the doctor. Genetic counseling and testing can
    determine the presence of the gene.
SUPPORT

The onset of stomach cancer can change a patient's life and as well
of the lives of their family and friends.
Needing help after receiving this
diagnosis is not uncommon, and there are many sources of support that help
patients deal with all of the emotions and concerns that the diagnosis brings.
Supportive care is available, before, during and after the treatment begins.
Support groups offer support in person, over the telephone, or on the internet.
In these groups patients and/or the family members will meet or talk
to other patients and their family members who will share their experiences
and acquired knowledge about how to deal with the disease and the effects
of the treatments,

Doctors, nurses and other members of your health care team are also
available to provide support and help deal with the emotions, concerns
and physical issues associated with the diagnosis of stomach cancer.

LOCATIONS


148 EAST AVENUE, SUITE 3A
NORWALK, CT 06851
203-899-0744

2 TRAP FALLS ROAD, SUITE 100
SHELTON, CT 06484
203-256-9707

778 LONG RIDGE ROAD, SUITE 101
STAMFORD, CT 06902
203-348-0589

52 WASHINGTON AVENUE, SUITE 3
NORTH HAVEN, CT 06473
203-285-2861

831 BOSTON POST ROAD, SUITE 202
MILFORD, CT 06460
203-647-0140

Dr. Craig Floch

the founder and senior partner of Fairfield County Bariatrics & Surgical Specialists, P.C. His commitment has enabled us to become one of the most prominent, dedicated, personal and highly respected practices serving Connecticut, New England and New York.

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Dr. Neil Floch

the Director of Minimally Invasive Surgery at Norwalk Hospital as well as the Bariatric Director of the Hospital. He is the first fellowship trained advanced Laparoscopic Surgeon in Fairfield County.

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Dr. Peter Ingraldi

is a partner of Fairfield County Bariatrics & Surgical Specialists, P.C. He joined our practice in 2007. Dr. Ingraldi specializes in general surgery and surgical critical care and is Board Certififed in both fields.

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Abe Fridman

joined our practice September 1, 2012. Dr. Fridman specializes in general and bariatric surgery.

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Dr. Marko Lujic

is the newest member of Fairfield County Bariatrics & Surgical Specialists, P.C., having joined our practice in October 2017. Dr. Lujic will lead our initiative in Milford and will provide comprehensive general surgical services, including breast surgery, thyroid surgery and melanoma in addition to managing traditional general surgery consultations.

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