Partial Gastrectomy

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. At present, therefore, resection usually involves 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, the 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]

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
• Primary gastric melanoma

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 (EGJ). 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 leakage is possible. ^[8] In these circumstances, other surgical options (eg, partial gastrectomy) may be necessary. The primary advantage of partial gastrectomy is that if there is a leak from the duodenum after 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 with end duodenal fistulas. ^[9] If the duodenum is unsuitable for a primary closure after 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 proximity to the greater curvature of the stomach. However, for larger tumors or tumors closer to the 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 and consequent 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 as a consequence of 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]

Primary gastric melanoma

Primary gastric melanoma (PGM), a rare entity, was reported in a systematic review that included 25 patients and was aimed at assessing the biologic behavior and preferred treatment approaches. ^[13]  The mean patient age in this study was 63.4 years, and the major symptoms were abdominal pain (64%), weight loss (48%), and hematemesis or melena (32%). Most commonly, the tumor was noted in the body of the stomach (54.2%), and the majority of the patients with resectable tumors (52%) underwent partial gastrectomy. The 5-year survival rate was 12%, with a median time to recurrence of 5 months.

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.

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 the 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.

In a study by Papenfuss et al, which included 1581 patients from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) who underwent partial gastrectomy for malignancy, the incidence of serious morbidity was 19.9%, and 30-day mortality was 3.4%. ^[14] Adding lymphadenectomy did not increase morbidity or mortality. 

Although total omentectomy (TO) is the recommended procedure for gastric cancer with T3 or deeper tumors, the literature has not provided sufficient supporting data for this recommendation.

In a study that included 341 patients with T3 or T4a gastric cancer who had undergone laparoscopic distal gastrectomy (LDG), Lee et al assessed the oncologic efficacy of TO (n = 167) against that of partial omentectomy (PO; n = 174) ^[15] ; after propensity matching for age, sex, T and N stage, tumor size, and degree of tumor differentiation, there were 107 patients in each group. Overall, no significant differences were observed in clinicopathologic features, short-term surgical outcomes, relapse-free survival (RFS), or peritoneal seeding-free survival (PSFS). The authors concluded that PO may be adopted during LDG for T3 or T4a gastric cancer without definite gross serosal exposure.

In a study of 1253 gastric cancer patients who underwent gastrectomy with total omentectomy, Lin et al also suggested that partial omentectomy might be practicable for patients with T3 or shallower tumors. ^[16]

In a study comparing Roux-en-Y with Billroth II reconstruction in 447 patients who underwent partial gastrectomy for gastric cancer, Tran et al did not find either approach to have an advantage over the other with respect to short-term perioperative outcomes (hospital stay, readmission rate, 90-day mortality, incidence and severity of complications, dependency on jejunostomy tube feeding at discharge, preoperative-to-postoperative decrease in serum albumin level, receipt of adjuvant therapy, and 5-year survival). ^[17]

Laparoscopic partial gastrectomy has been demonstrated to have oncologic outcomes similar to those of open surgery. In addition, the laparoscopic approach has resulted in less severe postoperative complications, shorter hospital stays, and reduced opioid use. ^[18]  Laparoscopic partial gastrectomy has become a common procedure for gastric submucosal tumors because of its accepted feasibility, safety, and oncologic outcomes. However, there remains a need for long-term postoperative outcome data, especially with respect to the location of submucosal tumors.

Hirota et al reviewed 52 patients with gastric submucosal tumors who underwent laparoscopic partial gastrectomy, dividing them into a lesser-curvature group (n = 23) and a greater-curvature group (n = 26) and comparing the two groups with respect to the following postoperative data ^[19] :

• Body weight change during the first postoperative year
• Gastrointestinal (GI) symptoms
• Amount of food residue at endoscopy
• Need for medications

The investigators found that these patients did not have severe body weight loss but that those in the lesser-curvature group were at higher risk for postoperative GI symptoms, which suggested that this group should receive special attention. ^[19]

The outcomes of robot-assisted partial gastrectomy were reported by Marano et al in a retrospective study that included 38 patients. ^[20]  In two patients, advanced disease and technical difficulties necessitated conversion to open technique. Mortality was zero, morbidity was 13.1%, and median overall survival was 70.9 months. Patients with positive nodes had poor 5-year survival compared with those whose nodal status was negative. Robot-assisted partial gastrectomy was found to be safe and feasible.