For a long time, a surgeon facing cancer in the upper stomach had to choose between two imperfect paths: removing a portion and living with painful reflux, or removing the whole organ and accepting a life of tiny meals. Mayo Clinic surgeon Travis Grotz describes a quiet turn in that story, in which older operations are being reconsidered and reshaped with techniques borrowed from neighboring fields. The aim, as he frames it, is no longer the largest possible operation but the right one for each patient, with the ordinary pleasures of eating preserved wherever possible. Behind this progress sit
Stomach Cancer Surgery Revisits Old Ideas and Builds New Reservoirs to Preserve Eating and Quality of Life
Treating the cancer while preserving as much normal life as possible
Mark
Why is an operation that was abandoned suddenly back?
Mimi
Because the reason it was dropped was specific: severe bile reflux. Mayo surgeons are using double-tract reconstruction to rewire the connections, and Grotz says reflux can be around 5%.
Mark
So the cancer treatment itself was never the issue.
Mimi
Right. It treated the cancer. The side effects hurt quality of life.
Luke
That 5% is Grotz's figure from his own center's approach. The piece doesn't say how many patients, or how long they were followed.
Mark
What about the J-pouch?
Mimi
It borrows from colorectal surgery. Grotz says it holds food about 90 minutes and releases it slowly, and that over 80% of patients with one return to about three normal meals a day.
Luke
Again, that's his estimate. It's encouraging, but not a published trial result as presented here.
Mark
And the rise in younger patients?
Mimi
Grotz says cancers are more often proximal and diffuse now, and in younger adults. His team is looking at ultraprocessed foods.
Luke
Which he says is only an association. Nothing here shows those foods cause it, and the cause of the shift is still unknown.
Der Puls
- A hard trade-off has long forced surgeons to choose between severe bile reflux and removing the entire stomach.
- The revived proximal gastrectomy, reconnected with double-tract reconstruction, is pulling part of the stomach back into the picture, with reflux reported in around 5% of patients.
- Surgeons are borrowing a J-pouch from colorectal surgery to replace the stomach's reservoir, and over 80% of patients with it return to roughly three normal meals a day.
- Early cancers may be removed endoscopically without any stomach removal, and surgery is increasingly paired with chemotherapy and immunotherapy.
- Rising early-onset cases raise alarm, but the suspected link to ultraprocessed food remains an association under study with large datasets and AI.
For a long time, a surgeon facing cancer in the upper stomach had to choose between two imperfect paths: removing a portion and living with painful reflux, or removing the whole organ and accepting a life of tiny meals. Mayo Clinic surgeon Travis Grotz describes a quiet turn in that story, in which older operations are being reconsidered and reshaped with techniques borrowed from neighboring fields. The aim, as he frames it, is no longer the largest possible operation but the right one for each patient, with the ordinary pleasures of eating preserved wherever possible. Behind this progress sits a less settled question about why stomach cancer is appearing in younger adults, a mystery that researchers are still working to understand.
For decades, a surgeon facing cancer in the upper stomach confronted a painful choice. Removing the top portion often meant severe bile reflux afterward, so many American surgeons instead removed the whole stomach. Travis Grotz, a Mayo Clinic surgical oncologist, says that older operation is now getting another look, thanks to a change in how the remaining pieces are reconnected. Double-tract reconstruction preserves part of the stomach while greatly reducing reflux, and Mayo surgeons have adapted it for the more advanced cancers seen in the U.S.
When the whole stomach must come out, surgeons are borrowing a J-pouch from colorectal surgery. It holds food for about 90 minutes before releasing it slowly, and Grotz estimates that more than 80% of patients with one return to roughly three normal-sized meals a day. Some early cancers need no major surgery at all and can be removed endoscopically at experienced centers, while most advanced cases are treated with a coordinated plan of chemotherapy, immunotherapy and surgery.
The disease is shifting too, with more cancers in younger adults. Grotz and colleagues are studying whether ultraprocessed foods play a role, but he stresses that the evidence so far shows only an association. The team is turning to large datasets and artificial intelligence to learn more.
For decades, a surgeon facing a cancer in the upper stomach had a choice that carried a hard trade-off. Remove the top portion and connect what remained straight to the esophagus, and patients often suffered severe bile reflux afterward. Or remove the whole stomach. Travis Grotz, M.D., a Mayo Clinic surgical oncologist who specializes in stomach cancer, says surgeons in the U.S. largely chose the second path. Now, he says, the first operation is getting another look.
That operation is the proximal gastrectomy. It treated the cancer effectively, Grotz says, but the reflux damaged patients' quality of life, and American surgeons eventually moved away from it. What has changed is the way the pieces are reconnected. A technique called double-tract reconstruction alters how the remaining stomach, the esophagus and the intestine are joined, preserving part of the stomach while cutting down on reflux. Mayo Clinic surgeons have adapted the approach for the more advanced cancers typically seen in the U.S. Grotz says reflux with the reconstruction can occur in around 5% of patients. For appropriate patients, surgeons can remove enough tissue to treat the cancer and still leave part of the stomach in place.
When the entire stomach does have to come out, the loss is considerable. The body no longer has a reservoir for food. Patients typically need five or six small meals a day and can develop dumping syndrome, in which food rushes into the small intestine. Here surgeons are borrowing from colorectal surgery, reshaping the small intestine into a J-pouch that takes over part of the stomach's job. According to Grotz, the pouch holds food for about 90 minutes and then releases it slowly. He estimates that more than 80% of patients with a pouch can return to roughly three normal-sized meals a day. "You really wouldn't even know they have it when you're eating," he says, adding that patients may eat a little slowly but still within the realm of normal.
Some patients may not need major surgery at all. Most stomach cancers in the U.S. are found after they have advanced, but those caught early can sometimes be removed through an endoscope, without removing the stomach. The procedure demands specialized expertise, and Grotz says that matters when choosing where to seek care: a patient offered a larger operation elsewhere might, after careful evaluation, qualify for endoscopic treatment at an experienced center. For those who do need an operation, minimally invasive and robotic techniques can lessen the physical burden.
For most patients with locally advanced disease, surgery is one part of a larger plan. Chemotherapy, immunotherapy and surgery increasingly work together, with the order tailored to the individual. Even some patients whose cancer has spread beyond the stomach may be considered for surgery if they respond well to systemic treatment. "Surgery is a great consolidative therapy," Grotz says, describing it as an effective way to remove what remains after a strong response to initial treatment.
The disease itself is also shifting. Decades ago, Grotz says, stomach cancer in the U.S. more often arose in the lower stomach and in older patients. Physicians now see more proximal and diffuse cancers, including in younger adults. Researchers are working to understand why. Grotz and colleagues are studying whether greater consumption of ultraprocessed foods may contribute to early-onset stomach cancer, a question he thinks deserves attention because today's younger adults encountered those foods earlier in life than previous generations did. He is careful to say that the current evidence shows an association, not proof of cause. The team is using large datasets and artificial intelligence to probe the relationship further.
Grotz frames the common thread as a change in aim: not the largest possible operation, but the right one for the cancer and its stage, whether that means an endoscopic removal, a preserved portion of stomach, a new reservoir, or surgery combined with systemic therapy. The test for patients, he says, is treating the cancer while preserving as much normal life as possible. The open question is the food link, which remains under study.
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You really wouldn't even know they have it when you're eating.— Dr. Travis Grotz, Mayo Clinic surgical oncologist
What we eat is going to affect our stomach; it's the first place it goes.— Dr. Travis Grotz, Mayo Clinic surgical oncologist
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