Gastric cancer is the sixth most common cancer in the world. Like most abdominal neoplasms, adenocarcinoma of the stomach arises from the mucosa of the stomach, then proceeds to invade first the loco-regional lymph nodes adjacent to the stomach and later may invade nearby organs, such as the pancreas, colon, spleen and liver. Through the blood, it can then metastasize to distant organs, such as the lung and liver, and sometimes can involve the peritoneum. There are risk factors such as infection with Helicobacter pylori, a family history of gastric cancer, excessive consumption of red meat, salted and smoked foods or preserved foods but also a diet low in fruits and vegetables as well as cigarette smoking. In addition to gastroscopy, the staging tests for gastric neoplasms are echo-endoscopy, CT scan of the chest and abdomen and in some cases total body PET scan. 

All patients with gastric neoplasia, as well as other neoplasms, are discussed in a multidisciplinary setting involving various figures such as the pathologist, medical oncologist, surgeon, nuclear physician, gastroenterologist, radiologist, nutritionist and radiation therapist). This happens regularly at Poliambulanza and allows for the creation of a personalized clinical pathway for each individual patient.

The therapy of gastric neoplasms varies depending on the patient and the preoperative staging of the neoplasm. The therapy of choice is certainly represented by surgery that in some cases is performed as a first approach while in other cases after a systemic chemotherapeutic treatment. The most frequently performed operations are the total gastrectomy that is the total removal of the stomach and the sub-total gastrectomy that is the removal of about 2/3 of the stomach. In addition to the removal of the stomach, the regional lymph nodes are removed at the same time, and in a variable percentage they can be the site of disease.

Personally, I prefer to approach this operation, when possible, by laparoscopic or robotic way in order to ensure a less invasive compared to the classic intervention obtained by traditional way. The use of minimally invasive methods such as laparoscopy or robotics is certainly an advantage for each patient.

In Fondazione Poliambulanza we try to approach gastric neoplasms as minimally invasive as possible. Minimally invasive surgery is that type of surgery where a wide cut is no longer made in the abdomen to remove the neoplasm but the same procedure is performed with small holes and a small incision for the extraction of the surgical piece. Laparoscopic surgery is performed using long dedicated forceps and a camera that transmits images to monitors in the operating room so that all surgeons involved can see the details of the surgery at the same time. The transmission and accuracy of the images is in 4K mode, i.e. with greatly increased definition. In some cases the laparoscopic intervention can be performed in three-dimensional mode, that is, with the use of a 3D camera that allows to give the sense of depth that in the classic monitors is not normally possible to have. All this technology has the sole purpose of increasing the accuracy of the surgery and consequently in an indirect way to improve the course of the patient's surgery and its postoperative course.

The evolution of the laparoscopic approach is represented by the use of the da Vinci robot. The da Vinci Xi robot is the version acquired from Fondazione Poliambulanza and is the latest model available on the market. The da Vinci robot is definitely the last frontier of the minimally invasive approach to neoplasms. It is composed of two distinct units both located inside the operating room, one part represents the operating console, i.e. the position where the surgeon is seated and controls the arms of the robot. The second part are instead the arms themselves (4 to be precise) that are connected to each other and are located above the patient allowing to govern with extreme precision the clamps and the various instruments inside the patient's belly.

The rationale for the use of the da Vinci robot is the extreme precision in movements as well as the definition of the surgical field that allows a better surgical tactic. The daVinci robot is routinely used for gastric and colorectal neoplasms. In situations where the tumor appears locally very large and judged not completely removable, chemotherapy can be implemented before surgery with the aim of reducing the neoplasm and make it removable with greater chances of radicality. This can be done as a precautionary treatment after surgery when the histological examination has identified risk factors for the recurrence of cancer (extension of the primary tumor, presence of locoregional lymph nodes with the presence of neoplastic cells, etc). In patients with distant metastases, chemotherapy is the treatment of choice.

Once the surgery has been performed, particular attention will be paid to the subsequent oncological and clinical-nutritional controls (weight, vitamin dosage, etc). As is the case for the clinical management of patients affected by other neoplastic diseases of the abdomen that are treated at Poliambulanza, even patients with gastric cancer have a well-defined clinical care path coded within the protocols ERAS or rapid postoperative recovery. This allows to obtain excellent results both in terms of perioperative complications and in terms of postoperative hospitalization.