Gastrectomy: What is it? Types, Historical Aspects, Indications, Contraindications, Risks and Post Surgery

It is the partial or total removal of the stomach. There are three main types of gastrectomy:

  • A partial gastrectomy is the removal of part of the stomach. The lower half is usually eliminated.
  • A complete gastrectomy is the removal of the entire stomach.
  • A sleeve gastrectomy is the removal of the left side of the stomach. This is usually done as part of a surgery to lose weight.

Removing the stomach does not take away the ability to digest liquids and foods. However, you may have to make several changes in your lifestyle after the procedure.

Your surgeon will remove the lower half of your stomach during a partial gastrectomy. They can also remove nearby lymph nodes if they have cancer cells .

Gastrectomy is defined as partial when a part of the stomach is surgically removed and as a whole when the entire stomach is removed.

Some authors further differentiate the different types of partial gastrectomy depending on the amount of stomach removed, as follows:

  • Antrectomy (30% resection).
  • Hemigastrectomy (50% resection).
  • Subtotal gastrectomy (80% resection).

This differentiation was useful in the era of resection surgery for ulcerative disease . The antrectomy was performed with truncal vagotomy as one of the surgical procedures for duodenal ulcer or pyloric channel ulcer.

The advent of effective medical treatment of ulcer disease meant that gastrectomy is increasingly used for gastric cancer. Currently, therefore, resection generally involves a subtotal or total gastrectomy.

Historical Aspects

The first stomach resection for cancer was performed by Jules Emile Pean in 1879. A year later, a Polish surgeon named Ludwik Rydygier performed a gastroenterostomy for the treatment of peptic ulcer, unfortunately, none of these attempts was successful.

In 1881, the Austrian surgeon Theodor Billroth performed a successful gastroduodenostomy in a 43-year-old woman with pyloric cancer. It was performed after a partial gastrectomy.

This procedure was later known as the Billroth I operation to differentiate it from the Billroth II operation , in which the gastrojejunal reconstruction was performed after a partial gastrectomy.

In 1885, when Billroth found a patient with a large pyloric tumor, instead of performing a gastroduodenostomy after a partial gastrectomy.

He performed a gastrojejunostomy proximal to growth as a bypass to relieve the symptoms of gastric outlet obstruction as a first stage procedure due to the poor general condition of the patient.

A second stage of tumor resection was performed and the terminal end of the stomach and the proximal end of the duodenum were closed. This was described by von Hacker as a partial gastrectomy of Billroth II .

In 1888, Kroenlein unsuccessfully tried to modify the partial gastrectomy of Billroth II by performing an end-to-end gastrojejunostomy that, one year later, was successfully demonstrated by von Eiselsberg . This procedure was modified in the following years by Mikulicz, Reichel, Polya and Finsterer .

In the current era, Polya gastrectomy with end-to-end retrocolic gastrojejunostomy has become a commonly used alternative to the Billroth II procedure, especially with a hand-sewn anastomosis technique.

Franz von Hofmeister described a partial gastrectomy with a retrocolic gastrojejunostomy involving the greater curvature, which was later modified by Hans Finsterer , and was known as the Finsterer-Hofmeister operation .

Indications

The indications for partial gastrectomy include the following:

  • Gastric cancer.
  • Recurrent ulcerative disease.
  • Large duodenal perforations.
  • Bleeding from gastric ulcer.
  • Gastrointestinal stromal tumors (GIST).
  • Corrosive stenosis of the stomach.

Gastric cancer

Partially distal partial gastrectomy (subtotal gastrectomy) is performed for gastric cancer in the antropyloric region.

When tumors are more proximal, total gastrectomy is preferred. The proximal partial gastrectomy together with the esophagectomy is performed for cancer of the esophagogastric junction.

The palliative distal partial gastrectomy is performed to bleed or obstruct antroploric growth.

Recurrent ulcerative disease

Recurrent ulcer has become very infrequent, due to the availability of drugs with a long-lasting acid reduction and different regimens with greater efficacy for the eradication of Helicobacter pylori infection.

Large Duodenal Perforations

These are defined as perforations of more than 1 cm. In large duodenal perforations, if the conventional Graham patch is performed, a postoperative leak is possible.

Under these circumstances, other surgical options may be necessary (eg, partial gastrectomy).

The main advantage of partial gastrectomy is that if there is a leak from the duodenum after partial gastrectomy, it forms an end fistula, while a lateral duodenal fistula occurs after a leak from the closure of the omentum patch.

It is well known that lateral duodenal fistulas have a low cure rate compared to terminal duodenal fistulas.

If the duodenum is not suitable for a primary closure after a partial gastrectomy, a tube duodenostomy may be performed to form a controlled duodenal fistula.

First Antral Tumors

Partial gastrectomy may be indicated for tumors of the antrum mucosa and antral tumors without involvement of the lymph nodes.

Gastrointestinal Stromal Tumors

The wedge resection of the tumor is suitable for small GISTs located in the vicinity of the greater curvature of the stomach.

However, for larger tumors or tumors closer to the lesser curvature, a partial gastrectomy or a subtotal gastrectomy may be necessary.

When the tumors are closer to the lesser curvature, there is the possibility of lesion of the branches of the vagus nerve and the consequent dysfunction of the pyloric sphincter; therefore, partial gastrectomy may be safer.

Corrosive Stomach Stenosis

Corrosive lesions of the alimentary tract predominantly affect the esophagus and the stomach. When corrosive injury occurs in the stomach in a limited way, it is usually found in the prepyloric region as a consequence of reflex pyloric spasm after ingestion of the corrosive agent.

This leads to a late complication of the pre-pyloric stenosis of the stomach. The commonly used treatment is a limited excision of the gastric stenosis of the stomach with gastroduodenal anastomosis ( Billroth I).

Contraindications

Partial gastrectomy is contraindicated in patients who are not suitable for general anesthesia.

Relative Contraindications

Anemia, hypoproteinemia, severe comorbid conditions, significant ascites, disseminated malignancy, and documented diffuse peritoneal metastases prevent anastomotic healing and cause gastrojejunal anastomosis or duodenal burst failure.

They can also lead to a delay in the healing of the abdominal wound, resulting in postoperative abdominal dehiscence.

Tumors of the stomach that attach to adjacent organs (eg, liver, pancreas, or posterior parietes) are relative contraindications, since en bloc resection of these organs or palliative resection for hemorrhage or obstruction can be performed.

Palliative resections for hemorrhage, perforation or obstruction may be performed despite fixation to the aforementioned organs.

The laparoscopic approach is relatively contraindicated in patients with a history of upper abdominal surgery. Severe adhesions can complicate the procedure and may cause unnoticed injuries to the intra-abdominal structures.

Technical Considerations

Prevention of Complications

When partial gastrectomy is performed as an elective procedure, the general condition of the patient should be improved as much as possible.

However, because the majority of patients who undergo partial gastrectomy may have gastric cancer, a prolonged preoperative period is not available for patient optimization.

However, correction of anemia with blood transfusions and adequate hydration in patients with obstruction of the associated gastric outlet can avoid complications.

Adequate exposure and access; gentle management of the stomach, duodenum and jejunum; absence of tension in the anastomosis; and a good surgical technique can prevent complications. The authors have a policy of not placing any clamp on the duodenum if a hand sewn closure is made.

Complete Gastrectomy

It is also called total gastrectomy, this procedure completely eliminates the stomach. Your surgeon will connect your esophagus directly to your small intestine. The esophagus usually connects your throat with your stomach.

Gastric band

Up to three quarters of your stomach can be removed during a sleeve gastrectomy. Your surgeon will cut the side of your stomach to make it into a tube shape. This creates a smaller and longer stomach.

Why is it possible that I need a Gastrectomy?

Gastrectomy is used to treat stomach problems that other treatments do not help. Your doctor may recommend a gastrectomy to treat:

  • Benign or non-cancerous tumors.
  • Bleeding.
  • Inflammation.
  • Perforations in the wall of the stomach.
  • Polyps or growths inside your stomach.
  • Stomach cancer.
  • Severe peptic or duodenal ulcers.

Some types of gastrectomy can also be used to treat obesity. By making the stomach smaller, it fills faster. This can help you eat less.

However, gastrectomy is only an appropriate obesity treatment when other options have failed. Less invasive treatments include:

  • Diet.
  • Exercise.
  • Medication.
  • Advice.

Who should not undergo a Gastrectomy?

Your doctor will look at the type and stage of your cancer, as well as any other health problems you have. Some, such as anemia and hypoproteinemia (low levels of protein in the blood), increase the chances of you having serious problems after this surgery.

How to prepare for a Gastrectomy?

Your doctor will order blood tests and imaging tests before surgery. This will ensure that you are healthy enough for the procedure. You will also have a complete physical examination and a review of your medical history.

During your appointment, tell your doctor if you are taking any medication. Be sure to include over-the-counter medications and supplements. You may need to stop taking certain medications before surgery.

You should also tell your doctor if you are pregnant, think you may be pregnant, or if you have other medical conditions, such as diabetes.

If you smoke cigarettes, you should stop smoking. Smoking adds extra time to recovery. It can also create more complications, especially those that involve infections and lung problems.

How is Gastrectomy Done?

You will have to go to the hospital for a gastrectomy. It may take 4 to 5 hours if the doctor makes a large incision (a cut) to remove the stomach. Or you can make several small cuts, called a laparoscopic gastrectomy. It takes less time, but it is not so used.

First, you will get anesthesia so that you sleep during the procedure. Once you’re underneath, a surgeon will make an incision in your belly. Through this, he will remove part or all of his stomach, as well as some nearby tissues, such as his nymphal nodules.

He will test the nodes to make sure the cancer has not spread. It is key that your doctor eliminate as much cancer as possible.

Depending on the type of procedure you have, the surgeon will decide the best way to rebuild your digestive tract.

There are two different ways to perform gastrectomy. All are performed under general anesthesia. This means that you will sleep soundly during the operation and you will not be able to feel any pain.

Open Surgery

Open surgery involves a single large incision. Your surgeon will remove the skin, muscles and tissues to access the stomach.

Laparoscopic surgery

Laparoscopic surgery is a minimally invasive surgery. It involves small incisions and specialized tools. This procedure is less painful and allows a faster recovery time.

It is also known as “keyhole surgery” or laparoscopic-assisted gastrectomy.

It is a more advanced surgery with a lower rate of complications.

Your surgeon may recommend open surgery on laparoscopic surgery to treat certain conditions, such as stomach cancer.

The Risks of Gastrectomy

The risks of a gastrectomy include:

  • Reflux.
  • Diarrhea.
  • Gastric emptying syndrome, which is a serious form of poor digestion.
  • An infection of the wound of the incision.
  • An infection in the chest.
  • Internal bleeding.
  • Sickness.
  • Vomiting
  • Acid in the stomach that leaks into the esophagus, which causes scarring, narrowing or constriction (stenosis).
  • A blockage of the small intestine.
  • Vitamin deficiency.
  • Weightloss.
  • Bleeding
  • Difficult breathing
  • Pneumonia.
  • Damage to adjacent structures.

Be sure to tell your doctor about your medical history and the medications you are taking. Follow all instructions given to prepare for the procedure. This will minimize your risks.

After the Gastrectomy

After the gastrectomy, your doctor will close your incision with stitches and the wound will be bandaged. They will take him to a hospital room to recover. A nurse will monitor your vital signs during the recovery process.

You can expect to stay in the hospital for a week or two after the surgery. During this period, you probably have a tube that goes from your nose to your stomach. This allows your doctor to eliminate the fluids produced by your stomach. This helps you not feel nauseous.

You will be fed with a tube in your vein until you are ready to eat and drink normally.

Tell your doctor immediately if you develop any new symptoms or pain that are not controlled by medication.

This is a major surgery, so it will take time for you to feel better. You will be in the hospital for about 4 days.

During the first days, you will not be able to eat any food. Then you will be on a clear liquid diet. This gives your digestive tract the opportunity to heal. Instead, you will be fed through an intravenous line in your vein or a catheter (tube) that is inserted into your stomach.

After about a week, you should be ready to begin a light diet again. Because your stomach is smaller now, be prepared to make some changes in your eating habits:

Small meals throughout the day : six small meals will be easier to digest than three large ones.

Drink and eat at different times : drink liquids 1 hour before or after meals instead of during them.

Look at your fiber intake : high-fiber foods like beans, lentils and whole grains can fill it up too quickly. Add them slowly.

Beware of dairy products : after this surgery, many people can not digest lactose, sugar in milk. If you are one of them, you will have gas, bloating and diarrhea after you have dairy products.

Take a supplement : some nutrients such as iron, calcium and vitamins B12 and D are more difficult for your body to absorb from food after a gastrectomy. Your doctor can do blood tests to check these levels.

If they are low, you may need to start taking a supplement.

Changes in lifestyle

Once you go home, you may have to adjust your eating habits. Some changes may include:

  • Eat smaller meals throughout the day.
  • Avoid foods with a high fiber content.
  • Eat foods rich in calcium, iron and vitamins C and D.
  • Take vitamin supplements.

The recovery of a gastrectomy can take a long time. Eventually, your stomach and small intestine will stretch. Then, you can consume more fiber and eat larger meals.

You will have to have blood tests regularly after the procedure to make sure you are getting enough vitamins and minerals.

Is There Any Secondary Effect?

I could have what is called dumping syndrome. When your small intestine has to digest a large amount of food at one time, you may vomit or have nausea, cramping or diarrhea. Many people notice these symptoms one hour after eating.

If you feel sick a few hours later, your blood sugar level may be going up and down too fast. It is common to sweat, have a fast heart rate or feel tired or confused.

Changing what you eat can help you control these symptoms. Remember, too, be patient. After your gastrectomy, it may take 3 to 6 months to adapt.