What are the steps and indications for a gastrectomy (surgical removal of the stomach)?

Gastrectomy: Indications and Surgical Steps

For curative-intent gastric cancer surgery, perform standard gastrectomy with resection of at least two-thirds of the stomach combined with D2 lymph node dissection, as this represents the principal surgical approach for improving survival and achieving oncologic control. 1

Primary Indications for Gastrectomy

Curative Intent (Gastric Cancer)

• Clinically node-positive (cN+) or T2-T4a tumors: Standard gastrectomy with D2 lymphadenectomy 1
• cT1N+ tumors: D2 lymphadenectomy indicated 1
• cT1N0 tumors: Modified approaches with D1 or D1+ lymphadenectomy depending on tumor characteristics 1

Palliative Intent

• Stage IV gastric cancer with bleeding or obstruction: Palliative gastrectomy or gastrojejunostomy is recommended for symptom relief in fit patients 1
• Stomach-partitioning gastrojejunostomy provides superior function compared to simple gastrojejunostomy for palliation 1

Non-Oncologic Indications

• Chronic gastric ulcer refractory to medical management 2
• Severe peptic ulcer disease complications 2

Critical caveat: Reduction surgery (gastrectomy for metastatic disease without urgent symptoms) has no proven survival benefit and should not be performed outside investigational settings, as demonstrated by the REGATTA trial 1

Types of Gastrectomy Based on Tumor Location

For cN+ or T2-T4a Tumors

Choose between total or distal gastrectomy based on the following algorithm 1:

• Distal gastrectomy: When adequate proximal resection margin can be achieved (see margin requirements below)
• Total gastrectomy: Required when:
  • Adequate proximal margin cannot be obtained 1
  • Pancreatic invasion requires pancreatectomy (regardless of tumor location) 1
  • Tumor along greater curvature with no. 4sb lymph node metastasis 1

For cT1cN0 Tumors (Early Gastric Cancer)

Multiple options based on precise tumor location 1:

• Total gastrectomy: Complete stomach removal including cardia and pylorus
• Distal gastrectomy: Pylorus included, cardia preserved; standard approach removes two-thirds of stomach
• Pylorus-preserving gastrectomy (PPG): Preserves upper third of stomach and pylorus with portion of antrum
• Proximal gastrectomy: Cardia removed, pylorus preserved
• Segmental gastrectomy: Circumferential resection preserving both cardia and pylorus

Special Considerations

• Esophagogastric junction adenocarcinoma (proximal side): Consider esophagectomy and proximal gastrectomy with gastric tube reconstruction 1

Critical Surgical Margins

Resection margins directly impact R0 resection rates and survival 1:

For T2 or Deeper Tumors

• Expansive growth pattern (Types 1 and 2): Minimum 3 cm proximal margin 1
• Infiltrative growth pattern (Types 3 and 4): Minimum 5 cm proximal margin 1
• When margins cannot be achieved: Mandatory frozen section examination of proximal resection margin 1

For T1 Tumors

• Minimum 2 cm gross resection margin 1
• Unclear tumor borders: Preoperative endoscopic clip marking based on biopsy results 1

Esophageal Invasion

• 5 cm margin not necessarily required, but frozen section examination is essential to ensure R0 resection 1

Extent of Lymph Node Dissection

The extent of lymphadenectomy is the most critical technical factor affecting oncologic outcomes 1:

D2 Lymphadenectomy (Standard for Advanced Disease)

• Indicated for: Potentially curable T2-T4 tumors and cT1N+ tumors 1
• Perform D2 whenever nodal involvement is suspected, as pre- and intraoperative nodal staging remains unreliable 1
• Lymphadenectomy is not associated with increased morbidity or mortality; rather, it decreases mortality (OR 0.468, p=0.028) 3

D1+ Lymphadenectomy

• Indicated for: cT1N0 tumors (except those meeting D1 criteria) 1

D1 Lymphadenectomy

• Indicated for:
  • T1a tumors not meeting EMR/ESD criteria 1
  • cT1bN0 differentiated-type tumors ≤1.5 cm diameter 1

Extended and Modified Procedures

Extended Surgery 1

• Combined organ resection: When adjacent organs are directly invaded by tumor
• Extended lymphadenectomy: Beyond D2 for select cases

Important warning: Additional major procedures significantly increase mortality risk 3:

• Splenectomy: OR 2.8 (p<0.001)
• Pancreatectomy: OR 3.5 (p=0.001)
• Colectomy: OR 3.6 (p<0.001)
• Esophagectomy: OR 3.5 (p=0.035)

Modified Surgery 1

• Reduced extent of gastric resection and/or lymphadenectomy for early-stage disease with favorable characteristics

Expected Morbidity and Mortality

Understanding complication rates is essential for informed consent and multidisciplinary planning 3:

Overall Outcomes

• Serious morbidity: 23.6% overall 3
• 30-day mortality: 4.1% overall 3

By Procedure Type

• Total gastrectomy: 29.3% serious morbidity, 5.4% mortality 3
• Partial gastrectomy: 19.9% serious morbidity, 3.4% mortality 3

Most Common Complications Requiring Reoperation 4

• Intestinal obstruction: 54.3% of reoperations (primarily adhesive, not technical failure)
• Intraabdominal bleeding: 9.3%
• Wound dehiscence/evisceration: 9.3%
• Anastomotic leakage: 4.2%
• Hospital mortality from complications: 6.2% 4

Critical pitfall: Short-term complications are surgery-related with high mortality (14.1%), emphasizing the need for meticulous surgical technique during initial operation 4

Postoperative Management Algorithm

Based on pathologic stage 1:

• p-Stage I: Observation only
• p-Stage II-III: Adjuvant chemotherapy
• Stage IV: Chemotherapy or best supportive care