Multivisceral Resection

What types of surgery are available to someone with gastric cancer?

Most patients who are diagnosed with resectable gastric cancer will have a gastrectomy. In short, this surgery cuts out part of (or the whole) stomach. Gastrectomy is usually accompanied by a lymphadenectomy, where some of the lymph nodes near the stomach are taken out too. This helps prevent the spread of disease.

But, in some cases it can be helpful to remove other organs in the abdomen as well. This might be necessary for two main reasons: firstly, if the cancer has directly spread to this area. Or, the doctor might think it is very likely that the cancer could spread to these organs and would remove them to avoid this.

Which other organs might be taken out in a surgery for stomach cancer? Why?

  • Spleen: a bean-shaped organ behind the left side of the stomach which acts similarly to a large lymph node
  • Liver: a large organ on the right side of the body which is important for removing toxins from our body, helping digest our food, and making important products such as proteins
  • Pancreas: a J-shaped organ found beneath the stomach and nestled in with the duodenum. It releases juices needed for digesting food, and hormones (like insulin) that help control our blood sugar.
  • Transverse colon: part of our large intestine that stretches across the waist. It contains mostly-digested foodstuffs on their way to being eliminated.
  • Duodenum: the first part of our small intestine. It receives foodstuffs right from the stomach and is important for absorbing nutrients and breaking down the material. This is where the food is mixed with fluids released from the liver and pancreas. So, the duodenum has a number of roles that are important to digestion!

These structures are particularly important to consider in gastric cancer because they are located near the stomach. This means that the cancer is more likely to spread to these locations than other places in the body which are further away.  Removing multiple organs is called a multivisceral resection; “multivisceral” literally means “more than one organ”.

How can a doctor tell if they got all the cancer out?

It is usually difficult to answer this question for sure, especially because cancer can recur if even one diseased cell is left in the body. But, a good way to assess if most of the tumor is removed is by looking at the margins (borders), using the R classification system. After a surgeon removes a tumor, the cut-out sample is sent to the lab. Here, a pathologist looks at the sample under a microscope and identifies what “margins” the surgery was able to achieve:

  • R0 Margins: complete (“curative”) resection. This means that all signs of cancer were removed. This is the best-case scenario!
  • R1 Margins: microscopic resection. A few cancer cells remain which are visible under a microscope.
  • R2 Margins: macroscopic resection. Part of the tumor remains, which is visible with the naked eye. This is not an ideal scenario, but it can sometimes happen. For example, if the whole tumor cannot be safely resected without damaging vital nearby structures (such as major blood vessels or organs). In this scenario, part of the tumor would have to be left behind in order to preserve the patient’s life.

These papers by Dr. Coburn and her research team try to address some major questions about when it is appropriate to remove multiple organs, which organs should be taken out, and what the consequences are.

A systematic review of spleen and pancreas preservation in extended lymphadenectomy for gastric cancer (2011)

  • Brar, Savtaj S., et al. “A systematic review of spleen and pancreas preservation in extended lymphadenectomy for gastric cancer.” Gastric Cancer 15.1 (2012): 89-99. Available from:
  • What question are they trying to answer?
    1. This paper looked at the pros and cons of removing the spleen and pancreas even if they do not show signs of hosting cancer cells themselves.
    2. This may be done if doctors think there is a chance that the cancer could spread to these organs.
    3. Or, it may be helpful to remove them to more easily cut out nearby lymph nodes.
  • How did they address this question?
    1. This paper reviewed 40 articles involving 6354 patients from around the world.
  • What did they find? Why is this important?
    1. Generally, they found that removing the spleen and pancreas seems to decrease complications in the short term. This means that patients who had their spleen and pancreas taken out had fewer side effects soon after surgery.
    2. However, taking out the spleen and pancreas did not significantly change overall survival compared to patients whose organs were not removed.
    3. This paper concluded that surgically removing the spleen and lymph nodes is not unsafe. But, the long-term benefits still need to be proven to decide whether or not this procedure is actually helpful.

Multivisceral resection for gastric cancer: a systematic review (2011)

  • Brar, Savtaj S., et al. “Multivisceral resection for gastric cancer: a systematic review.” Gastric Cancer 15.1 (2012): 100-107. Available from: doi:
  • What question was this paper trying to answer?
    1. The authors of this paper wanted to know if Multivisceral resection actually helps to get rid of more cancer cells without harming the patient.
    2. Specifically, they looked at patients with advanced gastric cancer (T4 tumors)
  • How did they address their research question?
    1. 17 articles from around the world were summarized in this paper.
    2. The organs most likely to be taken out in these research papers were: the spleen, pancreas, liver and transverse colon.
  • What did they find? Why is this important?
    1. They found that when patients had a multivisceral resection surgery but R0 margins were not achieved, overall survival was worse.
    2. Essentially, this means the patients lost multiple major organs but the cancer was still present. As a result of this situation, they were more likely to die.
    3. Because of the danger of taking out many organs, the multivisceral resection surgery should only be used in T4 patients when the cancer has definitely spread to these organs.
    4. So, multivisceral resection can be helpful only when it is able to get out all the cancer (that is, achieve R0 margins) in late stage patients.

Systematic review of pancreaticoduodenectomy for locally advanced gastric cancer (2011)

Roberts, Patrick, et al. “Systematic review of pancreaticoduodenectomy for locally advanced gastric cancer.” Gastric Cancer 15.1 (2012): 108-115. Available from: doi:

  • What question were the researchers trying to answer?
    1. When the pancreas is invaded by cancer, one option is a gastrectomy with a pancreaticoduodenectomy (PD). A PD takes out the diseased part of the pancreas and the duodenum around it.
    2. This study wanted to learn about the risks and benefits of PD for gastric cancer patients.
  • How did they address their question?
    1. This study reviewed 8 articles from around the world.
  • What did they find? Why is this important?
    1. PD can cause a complication called a pancreatic leak, which is when fluid from the pancreas begins to flow out. This can damage other nearby organs.
    2. Despite this, PD can be helpful for patients whose cancer has directly spread to the pancreas. In this case, it can increase overall survival if it helps to achieve R0 margins.
    3. Because of its complications, PD should not be used unless the cancer has spread directly to the pancreas. So, if the duodenum develops cancer but the pancreas doesn’t, PD may not be the best option.
    4. In both cases, advanced gastric cancer can be helped with the use of chemotherapy and/or radiation therapy.