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Partial Gastrectomy

  • Author: Vikram Kate, MBBS, PhD, MS, FRCS, FRCS(Edin), FRCS(Glasg), FACS, FACG, FIMSA, MAMS, MASCRS; Chief Editor: Vinay Kumar Kapoor, MBBS, MS, FRCS, FAMS  more...
 
Updated: Apr 08, 2015
 

Background

Gastrectomy is defined as partial when a part of the stomach is removed surgically and as total when the entire stomach is removed. Some authors further differentiate various types of partial gastrectomy on the basis of the amount of stomach removed, as follows:

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

This differentiation had utility in the era of resectional surgery for ulcer disease. 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; therefore, resection is usually either 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 gastroenterostomy for the management of peptic ulcer disease.[1] Unfortunately, both of these attempts were unsuccessful.[2]

In 1881, Austrian surgeon Theodor Billroth performed a successful gastroduodenostomy in a 43-year-old woman with pyloric cancer.[3] It was performed following partial gastrectomy. This procedure later came to be known as the Billroth I operation to differentiate it from the Billroth II operation, in which gastrojejunal reconstruction was performed following partial gastrectomy.

In 1885, when Billroth encountered a patient with a large pyloric tumor, instead of performing gastroduodenostomy following partial gastrectomy, he performed gastrojejunostomy proximal to the growth as a bypass to alleviate the symptoms of gastric outlet obstruction as a first­-stage procedure because of the poor general condition of the patient.[2] A second-stage resection of the tumor was performed, and the terminal end of the stomach and proximal end of the duodenum were closed.[2] This was described by von Hacker as Billroth II partial gastrectomy.

In 1888, Kroenlein unsuccessfully attempted modification of Billroth II partial gastrectomy by performing an end-to-side gastrojejunostomy, which, a year later, was successfully demonstrated by von Eiselsberg.[4, 5] This procedure was further modified in the following years by Mikulicz, Reichel, Polya, and Finsterer.

In the present era, the Polya gastrectomy with retrocolic end-to-side gastrojejunostomy has become a commonly performed alternative to the Billroth II procedure, especially with a handsewn anastomotic technique.[5] Franz von Hofmeister described a partial gastrectomy with a retrocolic gastrojejunostomy involving the greater curvature, which was modified later by Hans Finsterer, and it came to be known as the Finsterer-Hofmeister operation.[6]

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Indications

Indications for partial gastrectomy include the following:

  • Gastric cancer
  • Recurrent ulcer disease
  • Large duodenal perforations
  • Bleeding gastric ulcer
  • Gastrointestinal stromal tumors (GISTs)
  • Corrosive stricture of the stomach

Gastric cancer

Primarily distal partial gastrectomy (subtotal gastrectomy) is performed for gastric cancer in the antropyloric region. When the tumors are more proximal, total gastrectomy is preferred. Proximal partial gastrectomy along with esophagectomy is performed for cancer of the esophagogastric junction. Palliative distal partial gastrectomy is performed for bleeding or obstructing antropyloric growth.

Recurrent ulcer disease

Recurrent ulcer disease has become very infrequent owing to the availability of drugs with long-lasting acid reduction and different regimens with a greater efficacy for eradication of Helicobacter pylori infection.[7]

Large duodenal perforations

These are defined as perforations larger than 1 cm. In large duodenal perforations, if the conventional Graham patch is performed, postoperative leak is possible.[8] In these circumstances, other surgical options such as partial gastrectomy may be necessary. The primary advantage of partial gastrectomy is that if there is a leak from the duodenum following partial gastrectomy, it forms an end fistula, whereas a lateral duodenal fistula occurs following a leak from omental patch closure.

It is well known that lateral duodenal fistulas have a low healing rate compared to end duodenal fistulas.[9] If the duodenum is unhealthy for a primary closure following partial gastrectomy, a tube duodenostomy can be performed to form a controlled duodenal fistula.

Early antral tumors

Partial gastrectomy may be indicated for mucosal tumors of the antrum and antral tumors without lymph node involvement.[9]

Gastrointestinal stromal tumors

Wedge resection of the tumor is adequate for small GISTs located in the proximity of the greater curvature of the stomach. However, for larger tumors or tumors closer to lesser curvature, partial gastrectomy or subtotal gastrectomy may be needed. When tumors are closer to the lesser curvature, there is a possibility of injury to the vagal nerve branches leading to pyloric sphincter dysfunction; hence, partial gastrectomy may be safer.[10]

Corrosive stricture of the stomach

Corrosive injuries of the alimentary tract predominantly affect the esophagus and the stomach.[11] When the corrosive injury occurs in the stomach in a limited manner, it is usually in the prepyloric region owing to reflex pyloric spasm following ingestion of the corrosive agent. This leads to a delayed complication of prepyloric stricture of the stomach. A limited excision of the stricture of the stomach with gastroduodenal anastomosis (Billroth I) reconstruction is the treatment commonly used.[12]

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Contraindications

Partial gastrectomy is contraindicated in patients who are unfit for general anesthesia.

Relative contraindications

Anemia, hypoproteinemia, severe comorbid conditions, significant ascites, disseminated malignancy, and documented diffuse peritoneal metastases preclude anastomotic healing and lead to failure of gastrojejunal anastomosis or duodenal blowout. They can also lead to a delay in abdominal wound healing, resulting in postoperative abdominal dehiscence.

Tumors of the stomach that are fixed to adjacent organs (eg, the liver, pancreas, or posterior parietes) are relative contraindications, as en-bloc resection of these organs or palliative resection for bleeding or obstruction can be performed. Palliative resections for bleeding, perforation, or obstruction can be performed despite fixity 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 lead to inadvertent injury to the intra-abdominal structures.

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Technical Considerations

Complication prevention

When partial gastrectomy is performed as an elective procedure, the patient’s general condition should be improved to the extent possible. However, because most patients who undergo partial gastrectomy may have gastric cancer, a prolonged preoperative period is unavailable for optimization of the patient. Nonetheless, correction of anemia with blood transfusions and adequate hydration in patients with associated gastric outlet obstruction can prevent complications.

Adequate exposure and access; gentle handling of the stomach, duodenum, and jejunum; absence of tension at anastomosis; and good surgical technique can prevent complications. The authors have a policy of not placing any clamp on the duodenum if handsewn closure is performed.

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Outcomes

In a study by Papenfuss et al, which included 1581 patients from the American College of Surgeons National Surgical Quality Improvement Program who underwent partial gastrectomy for malignancy, the incidence of serious morbidity was 19.9%, and 30-day mortality was 3.4%.[13] Adding lymphadenectomy did not increase morbidity or mortality.

Intraoperative complications

Intraoperative complications may include injury to adjacent structures (eg, spleen, pancreas, liver, common bile duct) and/or intraoperative bleeding.

Early postoperative complications

Postoperative bleeding can result from patient-related factors or improper hemostasis during surgery. Luminal bleeding can occur from an anastomotic site, manifesting as fresh blood in the nasogastric tube.

Luminal bleeding can be managed with endoscopic localization and control with electrocautery or argon plasma coagulation (APC). However, when it is significant and persistent, reexploration may be required. The anastomosis is reopened and the bleeding is controlled by placement of running sutures through the anterior or posterior layer. In rare cases, intra-abdominal bleeding can result from slippage of ligatures;[14] however, it is usually not significant and can be managed with blood transfusions.

In a well-perfused stomach, anastomotic leakage is unusual. A leak indicates poor technique or poor tendency of the tissues to heal, owing to either hypoalbuminemia or tumor infiltration. It can present on the fourth to seventh postoperative day. It is associated with high morbidity and mortality.[14]

Computed tomography (CT) with oral contrast can be used to evaluate doubtful leaks. Minor leaks can be managed with a covered stent placed across the anastomosis and percutaneous aspiration or catheter drainage of the collection. Reexploration, drainage, and a feeding jejunostomy are required. Repeat leakage is likely, and the condition is managed as a case of enterocutaneous fistula.[15]

Meticulous care and handling of the tissues is necessary during the index operation to prevent these complications. The patient should not be rushed into surgery, and the nutrition status of the patient should be optimized preoperatively.

Duodenal stump blowout is suspected when bile is found in the drain. A conservative line of management can be adopted in the absence of peritoneal signs. If peritoneal signs are present, repeat laparotomy, lavage, and tube duodenostomy may be required.

Delayed complications

Delayed complications are also labeled as postgastrectomy syndromes.

Dumping syndromes are differentiated as early and late syndromes. Early dumping results from rapid presentation of increased osmotic load to the duodenum, leading to a shift of fluid from the intravascular compartment to the duodenum and a resultant hyperperistaltic response from the duodenum. Clinical manifestations are light headedness, palpitations, and crampy abdominal pain.[16]

Late dumping occurs about 2-3 hours after a meal and is attributed to rapid gastric emptying, leading to postprandial hyperglycemia, which further triggers a hyperinsulinemic response.[17, 18] Most patients with these symptoms respond to modifications in the amount and frequency of feeding. The symptoms are self-limiting, and spontaneous resolution is the rule.

Malnutrition is less common after partial than after total gastrectomy. Iron-deficiency anemia, calcium deficiency, and vitamin B12 deficiency are prominent features owing to the interruption of the natural metabolic process.[19] Parenteral vitamin B12 supplementation helps prevent pernicious anemia. Weight loss after gastrectomy is an unavoidable complication, and patients need to be sensitized to its occurrence.

Recurrent ulcer may develop.

Gastric stump cancer is more common after Billroth II than after Billroth I reconstruction. Enterogastric reflux, achlorhydria, bacterial overgrowth, and H pylori infection are the major factors involved in pathogenesis. The risk of stump carcinoma is time-dependent, usually occurring 10 years or longer after gastric resection. Patients with stump carcinoma typically present late in the course with more advanced disease. Operable tumors would require a total gastrectomy with Roux-en-Y reconstruction. The prognosis in these patients is generally poor.

Obstruction of the afferent or efferent loops of jejunum can present with distinct features.[20, 21, 22] Afferent loop syndrome presents as periods of intense abdominal pain relieved with vomiting large volumes of bile. The vomitus consists of undigested food in cases of efferent loop obstruction. Reoperation may be required if the obstruction is persistent and cannot be managed by conservative means.

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Contributor Information and Disclosures
Author

Vikram Kate, MBBS, PhD, MS, FRCS, FRCS(Edin), FRCS(Glasg), FACS, FACG, FIMSA, MAMS, MASCRS Professor of General and Gastrointestinal Surgery and Senior Consultant Surgeon, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), India

Vikram Kate, MBBS, PhD, MS, FRCS, FRCS(Edin), FRCS(Glasg), FACS, FACG, FIMSA, MAMS, MASCRS is a member of the following medical societies: American College of Gastroenterology, American College of Surgeons, American Society of Colon and Rectal Surgeons, Royal College of Surgeons of England, Royal College of Physicians and Surgeons of Glasgow, Royal College of Surgeons of Edinburgh

Disclosure: Nothing to disclose.

Coauthor(s)

Nanda Kishore Maroju, MBBS, MS, DNB, MRCS Assistant Professor of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, India

Nanda Kishore Maroju, MBBS, MS, DNB, MRCS is a member of the following medical societies: Royal College of Surgeons of Edinburgh

Disclosure: Nothing to disclose.

Anahita Kate, MBBS Compulsory Rotatory Intern, Jawaharlal Institute of Postgraduate Medical Education and Research, India

Disclosure: Nothing to disclose.

Madhuvanti Karthikeyan Jawaharlal Institute of Postgraduate Medical Education and Research, India

Disclosure: Nothing to disclose.

Chief Editor

Vinay Kumar Kapoor, MBBS, MS, FRCS, FAMS Professor of Surgical Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, India

Vinay Kumar Kapoor, MBBS, MS, FRCS, FAMS is a member of the following medical societies: Association of Surgeons of India, Indian Association of Surgical Gastroenterology, Indian Society of Gastroenterology, Medical Council of India, National Academy of Medical Sciences (India), Royal College of Surgeons of Edinburgh

Disclosure: Nothing to disclose.

Acknowledgements

The authors would like to thank the residents of the Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India, for their assistance with the images for this article.

References
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(a) Subtotal gastrectomy in progress. Linear stapler is being positioned on first part of duodenum for stapling and transection. (b) Linear stapler in situ (before removal) on distal end of first part of duodenum following stapling and transection. Transected proximal end of duodenum is held in occlusion clamp.
Diagrammatic representation of proximal line of resection on stomach for hemigastrectomy and subtotal gastrectomy.
Gastrojejunal anastomosis in progress. Stomach is not resected till last layer is completed so as to prevent retraction of stomach.
Stapled subtotal gastrectomy. Linear cutter is used for partial transection of stomach.
Stapled subtotal gastrectomy. Partial transection of stomach is carried out.
Stapled subtotal gastrectomy. Open part of stomach is anastomosed to jejunum.
Stapled subtotal gastrectomy. Gastrojejunostomy is completed by combination of stapled and handsewn technique. Note seromuscular sutures used to fix jejunum to transected stomach.
Postgastrectomy reconstruction.
 
 
 
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