Gastrectomy Procedure: Considerations and Management
The standard surgical procedure for clinically node-positive (cN+) or T2-T4a gastric tumors is either total or distal gastrectomy with D2 lymphadenectomy, with the specific approach determined by tumor location, histological type, and ability to achieve adequate resection margins. 1
Types of Gastrectomy
Selection Based on Tumor Characteristics:
Total gastrectomy: Complete removal of the stomach including cardia and pylorus
- Indicated for proximal tumors, tumors along greater curvature of corpus/fundus
- Mandatory when pancreatic invasion requires pancreatectomy regardless of tumor location
- Required when tumors along greater curvature have metastasis to no. 4sb lymph nodes
Distal gastrectomy: Removal of pylorus with preservation of cardia
- Preferred when adequate proximal margin can be obtained for distal tumors
- Standard procedure removes approximately two-thirds of the stomach
Proximal gastrectomy: Removal of cardia with preservation of pylorus
- For proximal tumors where more than half of distal stomach can be preserved
- For adenocarcinoma on proximal side of esophagogastric junction
Pylorus-preserving gastrectomy (PPG): Preserves upper third of stomach and pylorus
- For tumors in middle portion with distal border at least 4cm from pylorus
Resection Margins
Adequate margins are crucial for curative intent:
T2 or deeper tumors:
- Expansive growth pattern: ≥3cm proximal margin
- Infiltrative growth pattern: ≥5cm proximal margin
- Frozen section examination recommended when these margins cannot be achieved
T1 tumors: 2cm gross resection margin
- Preoperative endoscopic marking with clips helpful when tumor border is unclear
Lymph Node Dissection
The extent of lymphadenectomy depends on tumor stage:
D1 lymphadenectomy: For T1a tumors not meeting criteria for endoscopic resection, and cT1bN0 differentiated-type tumors ≤1.5cm
D1+ lymphadenectomy: For other cT1N0 tumors
D2 lymphadenectomy: For potentially curable T2-T4 tumors and cT1N+ tumors 1
Reconstruction Methods
After gastrectomy, reconstruction options include:
After distal gastrectomy: Roux-en-Y reconstruction generally superior to Billroth I and II in terms of functional outcomes and long-term endoscopic results 1
After total gastrectomy: Roux-en-Y reconstruction is the standard approach with satisfactory functional results 1
Combined Resection Considerations
Splenectomy: Generally associated with increased postoperative complications
- Only recommended for tumors along greater curvature or with macroscopic involvement of stations 4sa or 10 1
Omentectomy: Removal of greater omentum is standard for T3 or deeper tumors
- For T1/T2 tumors, omentum >3cm from gastroepiploic arcade may be preserved
Adjacent organ resection: May be performed when primary or metastatic lesion directly invades adjacent organs to achieve R0 resection 1
Palliative Surgery
- For advanced/metastatic gastric cancer with serious symptoms (bleeding, obstruction)
- Options include palliative gastrectomy or gastrojejunostomy based on resectability and surgical risks
- Stomach-partitioning gastrojejunostomy superior to simple gastrojejunostomy for function 1
Postoperative Complications and Management
Common complications requiring reoperation include:
- Intestinal obstruction (most common long-term complication)
- Intraabdominal bleeding
- Wound dehiscence
- Anastomotic leakage
- Duodenal stump leakage 2
Nutritional Considerations
- Total gastrectomy patients are at higher risk for nutritional deficiencies
- Weight loss is typically greater after total gastrectomy (15.0%) compared to proximal gastrectomy (10.8%) at 3 years 3
- Lifetime monitoring required for nutritional sequelae including vitamin B12, iron, and calcium replacement 1
- Consider feeding tube placement for patients undergoing total gastrectomy who will receive postoperative therapies 1
Laparoscopic Approach
- Can be considered for cStage I cancer indicated for distal gastrectomy
- Offers superior short-term outcomes but requires sufficient surgical expertise
- Long-term oncological outcomes still being evaluated in ongoing trials 1
Follow-up After Curative Treatment
- Should include monitoring for cancer recurrence, management of postgastrectomy symptoms, and nutritional support
- Follow-up by multidisciplinary team including gastroenterologist, surgeon, and oncologists
- Upper GI endoscopy may detect local recurrence or metachronous primary cancer in subtotal gastrectomy patients 1
Proper patient selection, meticulous surgical technique, and comprehensive postoperative care are essential for optimizing outcomes after gastrectomy.