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Stomach Resection/Total Gastrectomy


Medical editor Geir Rønning MD
Gastroenterological Surgeon
Oslo University Hospital

General

A stomach resection/total gastrectomy is mostly performed for cure. There is no agreement on how extensive the lymph node dissection should be. In Japan and some treatment centers in the West, an extensive dissection is performed (D2 resection). This has not been common in Norway. It has been shown that a splenectomy or particulary distal resection of the pancreas should not be routinely performed as either may increase morbidity and mortality. Studies have shown that an extensive lymph node dissection can be performed with low mortality and morbidity when it is centralized to departments with a high volume of treatments and special competence.

Surgery has two phases:

  • Resection of stomach tumor with lymph nodes en bloc
    • Either stomach resection of distal tumor in the stomach
    • Or total gastrectomy for proximal tumor (cardia/body) or diffuse growing tumor
  • Reconstruction of digestive tract

Contraindications

  • Distant metastasis and peritoneal carcinosis
  • Local invasion of pancreas, aorta, transverse colon, and hepatoduodenal ligament 
  • Other complicating illness 

Goal

  • Curative

Equipment

  • Laparotomy tray
  • Self-retaining retractor which lifts the costal arch 
  • Staple instruments: closing-splitting/long cross-stapling  

Preparation

  • Thrombosis prophylaxis 
  • Antibiotic prophylaxis
  • Epidural catheter is placed for postoperative pain treatment.  
  • Preoperative bowel emptying is not done.

Implementation

Resection

  • A midline incision is made in the epigastrium to below the umbilicus. 
  • The abdomen is examined for metastasis. 
  • The major omentum is divided from the transverse colon, the minor omentum from the liver.
  • The duodenum is mobilized and devided with a stapling instrument distal to the pylorus.  
  • The coeliac trunk is identified with lymph nodes.
  • Thel left gastric artery is identified and divided.
  • If necessary, the short gastric vessels are cut and the stomach is isolated to the esophagus.
  • The stomach is divided at the desired level with stapler.
  • Lymph nodes are dissected around the coeliac trunk, along the splenic vessels, and liver hilus according to the local policy.
  • The vagus nerves are cut at the cardia for total gastrectolmy.

Reconstruction

After the stomach resection, the proximal stomach can be anastomosized to:

  • (Billroth-I operation) the duodenal stump, end-end
  • (Billroth-II operation) proximal jejunum, end-side with or without side-side enteroanastomosis
  • (Roux-en-Y) proximal jejunum end-side with end-side enteroanastomosis

After a total gastrectomy, the esophagus is anastomosized to the proximal jejunum  (Roux-en-Y).

In certain cases, a feeding tube is inserted for early enteral nutrition in the jejunum.


Follow-up

  • Nasogastric tube, if used, is removed when the bowel has resumed function.
  • After a total gastrectomy, a contrast X-ray examination is performed only if there is suspect anastomosis failure. The patient may eat early.
  • After a gastric resection, the patient may usually drink/eat immediately after the operation.

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