What are the indications, surgical steps, and types of gastrectomy?

Gastrectomy: Indications, Types, and Surgical Steps

For clinically node-positive or T2-T4a gastric tumors, perform either total or distal gastrectomy with D2 lymphadenectomy as the standard curative approach, selecting the specific type based on tumor location and ability to achieve adequate resection margins 1.

Indications for Gastrectomy

Curative Intent

• Gastric adenocarcinoma (T1b-T4a tumors not amenable to endoscopic resection)
• Early gastric cancer (cT1N0) when endoscopic mucosal resection/endoscopic submucosal dissection criteria are not met
• Advanced gastric cancer (T2-T4a) with curative potential
• Esophagogastric junction adenocarcinoma on the proximal side 1, 2

Palliative Intent

• Bleeding from advanced/metastatic gastric cancer causing serious symptoms
• Gastric outlet obstruction in patients with incurable disease
• Palliative gastrectomy or gastrojejunostomy selected based on primary tumor resectability and surgical risk 1, 2

Critical Pitfall: Reduction surgery (gastrectomy without urgent symptoms in metastatic disease) is not recommended—the REGATTA trial found no survival benefit 1.

Types of Gastrectomy

The Japanese Gastric Cancer Treatment Guidelines provide the most comprehensive classification 1:

Standard Resections

Total Gastrectomy

• Complete stomach resection including cardia and pylorus
• Mandatory for: Pancreatic invasion requiring pancreatectomy (regardless of tumor location)
• Consider for: Tumors along greater curvature with No. 4sb lymph node metastasis, even if distal gastrectomy technically possible 1

Distal Gastrectomy

• Resection including pylorus, preserving cardia
• Standard approach removes two-thirds of stomach
• Selected when: Satisfactory proximal resection margin achievable 1

Proximal Gastrectomy

• Resection including cardia (esophagogastric junction), preserving pylorus
• Indicated for: Adenocarcinoma on proximal side of esophagogastric junction with gastric tube reconstruction 1, 3

Pylorus-Preserving Gastrectomy (PPG)

• Preserves upper third of stomach, pylorus, and portion of antrum
• For select cT1cN0 tumors based on location 1

Segmental Gastrectomy

• Circumferential resection preserving both cardia and pylorus
• Limited to specific cT1cN0 cases 1

Extended Surgery

• Gastrectomy with combined resection of adjacent involved organs (T4 tumors)
• Extended lymphadenectomy exceeding D2 (investigational) 1

Surgical Steps and Technical Principles

Resection Margins (Critical for R0 Resection)

For T2 or Deeper Tumors 1:

• Expansive growth pattern (types 1 and 2): ≥3 cm proximal margin
• Infiltrative growth pattern (types 3 and 4): ≥5 cm proximal margin
• When margins cannot be achieved: frozen section examination mandatory

For T1 Tumors 1:

• Gross resection margin: ≥2 cm
• If tumor border unclear: preoperative endoscopic clip marking based on biopsy results

For Esophageal Invasion:

• 5-cm margin not necessarily required
• Frozen section examination of resection line desirable for R0 resection 1

Lymph Node Dissection

The extent of lymphadenectomy is algorithmically determined by tumor stage 1:

D1 Lymphadenectomy

• Indicated for:
  • T1a tumors not meeting EMR/ESD criteria
  • cT1bN0 tumors that are differentiated type and ≤1.5 cm diameter
• Includes gastrectomy with resection of greater and lesser omenta (perigastric nodes along right/left cardiac, lesser/greater curvature, suprapyloric, infrapyloric areas) 2

D1+ Lymphadenectomy

• Indicated for: cT1N0 tumors not meeting D1 criteria 1

D2 Lymphadenectomy (Standard for Advanced Disease)

• Indicated for:
  • Potentially curable T2-T4 tumors
  • cT1N+ tumors
  • Any cN+ or cT2-T4 tumors (since preoperative nodal staging is unreliable) 1
• D1 dissection plus nodes along left gastric artery, common hepatic artery, celiac artery, splenic hilum, and splenic artery
• Goal: Examine ≥15 lymph nodes 2

Splenectomy Considerations:

• Not routinely performed (JCOG 0110 trial showed non-inferiority of spleen preservation for overall survival) 1
• Acceptable when: Spleen or hilum directly involved by T2-T4 tumor, or tumor located in greater curvature of upper stomach 1

Reconstruction Approaches

After total gastrectomy, reconstruction options include:

• Roux-en-Y esophagojejunostomy (most common)
• Jejunal pouch reconstruction (may improve postoperative quality of life) 4

After distal gastrectomy:

• Billroth I or II reconstruction
• Roux-en-Y gastrojejunostomy

Consider feeding jejunostomy tube in select patients, especially if postoperative chemoradiation likely 2.

Minimally Invasive Approaches

Laparoscopic and robotic-assisted gastrectomies are now standard options with evidence showing 5, 6:

• Reduced postoperative pain
• Quicker recovery
• Lower morbidity
• Oncologically safe results confirmed by multiple randomized trials
• Robotic surgery provides similar outcomes with some procedural benefits (though higher cost)

The shift from open to minimally invasive approaches represents a major evolution since the first open partial gastrectomy in 1881 6.

Key Clinical Pitfalls

1. Do not perform reduction surgery in metastatic gastric cancer without urgent symptoms—no survival benefit demonstrated 1

2. Do not routinely perform splenectomy for D2 dissection—spleen preservation is non-inferior for survival 1

3. Do not rely on preoperative nodal staging alone—perform D2 lymphadenectomy whenever nodal involvement suspected, as pre/intraoperative diagnosis remains unreliable 1

4. Always obtain frozen section when adequate resection margins cannot be achieved to ensure R0 resection 1

5. For palliative gastric outlet obstruction, gastrojejunostomy (open or laparoscopic) is preferable to endoluminal stenting in patients fit for surgery with reasonable prognosis 2