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.

Partial gastrectomy performed in a medically fit patient results in lower mortality and morbidity than total gastrectomy does.

Patients should be aware of the extent of surgery and the physiologic disturbances that can result from it. Complications such as postoperative bleeding, delayed gastric emptying, early satiety, and nutritional deficiencies should be explained.

Partial gastrectomy is performed in an operating theater. The operating theater should be adequately equipped with the necessary surgical instruments and supplies, including suture materials (especially synthetic absorbable sutures), an ultrasonic scalpel, and staplers (circular, linear, and linear cutting). Appropriate laparoscopic instruments and monitors should be available for the performance of a laparoscopic partial gastrectomy.

Patients with an obstructed stomach benefit from nasogastric decompression, gastric lavage, and fluid resuscitation. Nutritional status has a direct bearing on good anastomotic healing and should be optimized before surgery. Anemia, hypoproteinemia, and hypokalemia should be adequately corrected.

Anesthesia

General anesthesia with endotracheal intubation is standard practice. An epidural catheter can be placed for postoperative analgesia.

Positioning

Patients are positioned supine in a slight reverse Trendelenburg position.

Gastrectomy is defined as partial when a part of the stomach is removed surgically and as total when the entire stomach is removed. Various types of partial gastrectomy may also be differentiated on the basis of the amount of stomach removed, as follows:

• Antrectomy (30% resection)
• Hemigastrectomy (50% resection)
• Subtotal gastrectomy (80% resection; see the video below)

Patients with a malignancy in whom partial gastrectomy is planned can undergo a staging laparoscopy to assess the extent of the tumor and metastasis. Laparoscopy may detect peritoneal dissemination or liver metastasis that was not detected by conventional methods of imaging and other modalities. It is a safe and effective method of staging that can be helpful in avoiding nontherapeutic explorations and providing a guideline for appropriate treatment planning.

Incision

An upper midline incision from the xiphoid process to the umbilicus with an optional extension inferior to the umbilicus provides quick and bloodless access to the abdomen. Another option is a chevron or rooftop incision. This, combined with self-retaining subcostal retractors, provides excellent access to the upper abdomen.

A thorough exploration of the abdominal cavity to look for metastasis in the liver, peritoneum, omentum, and pelvis is performed first.

Further elements of the procedure depend on the choice of reconstruction. After resection of the stomach, continuity can be achieved with a gastroduodenal anastomosis (Billroth I). A tension-free gastroduodenal anastomosis requires good duodenal mobilization.

The second option is to close the duodenal end and to perform a gastrojejunal anastomosis (Billroth II or its modifications). Several techniques have been described for the gastrojejunal anastomosis, and a description of each technique is beyond the scope of this topic. Two main variations to the gastrojejunal anastomosis include an end-to-side gastrojejunostomy using an uninterrupted loop of jejunum and an end-to-side gastrojejunostomy to a Roux loop.

Gastroduodenal anastomosis, when possible, is preferred because it maintains the physiologic route of gastric emptying. However, it is not technically feasible if a more extensive gastric resection is necessary or if duodenal mobilization is difficult owing to inflammation or adhesions, in which cases a gastrojejunal anastomosis is recommended.

Duodenal mobilization

If the intention is to perform a gastroduodenal anastomosis, the first step is duodenal mobilization. The duodenum is mobilized by incising the peritoneum along its lateral border and then reflecting the duodenum to the left side until the inferior vena cava is exposed. This process is also referred to as kocherization. Care should be taken to avoid injury to the structures in the lesser omentum and middle colic vessels while mobilizing the duodenum.

Omental mobilization

The greater omentum is freed from the transverse colon by dividing along the avascular plane between the transverse colon and the anterior leaf of the omentum. It is easier to identify an avascular window along the left half of the transverse colon. Further division of the omental reflection is extended toward the right side.

This step carries the potential of inadvertent injury to the middle colic artery. Such an injury can be avoided by spreading the gastrocolic omentum along the greater curvature to clearly visualize and demonstrate the vascular pattern of the gastroepiploic vessels and lifting the transverse colon intermittently to clearly visualize the vascular pattern of the transverse colon. As the lesser sac is entered, the posterior wall of the stomach is visible.

The posterior wall of the stomach is freed by dividing gastropancreatic folds of peritoneum. The lesser omentum is separated from the undersurface of the liver for malignancy and along the lesser curvature for ulcer disease.

Duodenal division

The right gastric artery is identified at the inferior end of the lesser curvature as originating from the proximal hepatic artery or the gastroduodenal artery. This is doubly ligated and divided. Similarly, the gastroepiploic artery is identified close to the inferior end of the greater curvature, doubly ligated, and divided.

At this point, about 1-2 cm of duodenum adjacent to the pylorus is cleared of all fat and vascular adhesions. Care is taken to avoid injury to the pancreatic tissue while clearing the duodenum. The duodenum is divided by a linear cutter or linear stapler at this level (see the image below).

Gastric division

Further mobilization of the stomach is easier after duodenal division.

The greater curvature of the stomach is mobilized further by dividing the gastrosplenic ligament. Depending on the extent of the planned gastrectomy, the greater curvature is mobilized to the point where the gastroepiploic artery is closest to the gastric wall (hemigastrectomy) or farther proximally to the second short gastric artery (subtotal gastrectomy). The first short gastric artery is left behind to supply the remnant stomach.

Similarly, the point of division of the stomach along the lesser curvature is marked at the level of the third prominent vein (hemigastrectomy) or about 1 cm inferior to the esophagogastric junction (EGJ; subtotal gastrectomy) (see the image below).

The left gastric artery is divided as a part of subtotal gastrectomy. This artery divides into two branches close to the lesser curvature. The left gastric artery is secured via double ligation or ligation followed by a transfixing suture on the arterial side and a tie on the gastric side before being divided.

The lesser and greater curvatures should be prepared at the elected site and omental fat cleared at the line of section for a couple of centimeters.

The stomach is divided with a linear cutter at the site identified for proximal resection. At this stage, the specimen is delivered out.

Lymph node dissection

According to the Japanese Gastric Cancer Association, lymph node dissection can be categorized as D1, D2, D3, or D4 on the basis of the lymph node stations, as follows[21] :

• D1 lymphadenectomy - Removal of perigastric nodes (3 cm around tumor)
• D2 lymphadenectomy - Removal of nodes along the left gastric artery, common hepatic artery, celiac trunk, splenic hilus, and splenic artery
• D3 lymphadenectomy - Include dissection of lymph nodes along the hepatoduodenal ligament, posterior surface of the head of the pancreas, and the root of the mesentery (superior mesenteric vessels)
• D4 lymphadenectomy - Dissection along the para-aortic and paracolic region

Resection of adjacent organs

Resection of adjacent organs (eg, distal pancreas, spleen, colon) is performed for lesions with direct involvement into these structures. Distal pancreatectomy and splenectomy are not performed as part of a conventional D2 lymphadenectomy, owing to increased postoperative morbidity and mortality.

Reconstruction

Either a Billroth I or a Billroth II reconstruction is performed.

Billroth I

A part of the staple line on the gastric side in the inferior aspect toward the greater curvature is opened up corresponding to the duodenal end diameter. Interrupted delayed absorbable sutures are taken from the middle of the posterior walls of the stomach and the duodenum. After all sutures are placed along the posterior layer, they are tied, starting from the lesser-curvature side. Once secured, the anterior layer is then similarly sutured.

Billroth II

The duodenal stump remains closed. A loop of jejunum is identified close to the duodenojejunal flexure. Care should be taken to keep the afferent loop reasonably short. The loop is anchored along its axis and isoperistaltic to the posterior wall of the stomach with delayed absorbable seromuscular sutures. An opening is made in the jejunum equal to about twice the diameter of the jejunal lumen. The staple line on the stomach is opened to correspond to this length.

The anastomosis is performed with a continuous absorbable suture that starts from the middle of the posterior layer on either side and is continued to meet in the middle of the anterior layer. A fourth layer of seromuscular sutures is placed to bury the anterior continuous suture line (see the image below).

The principles of gastrojejunal anastomosis remain similar for a Roux-en-Y anastomosis. Instead of a conventional Polya complete anastomosis, a Hofmeister-Finsterer modification can be performed, in which the part of the opening in the stomach on the lesser-curvature side is closed and fixed to the jejunum with seromuscular sutures so as to narrow the anastomosis and thus exert a valvular effect. This is more useful in patients who are undergoing stomach resection for benign conditions when the conventional Polya anastomosis may be very wide (see the image below).

The abdominal wound is lavaged thoroughly. A right subhepatic drain is useful in early detection of a possible duodenal stump blowout. The abdominal wound is then closed in layers.

A 30-mm linear cutter is applied at the desired level of section over the duodenum. Adequate care is taken to prevent inclusion of any other structures, including mesentery, before firing the stapler. Linear staplers can be similarly used to section the stomach. Because the stomach is fairly wide, it may be necessary to fire the stapler sequentially.

Once divided, a loop of jejunum is anchored to the posterior wall of the stomach with seromuscular stay sutures. The jejunal loop can also be anchored by using Babcock forceps. A small enterotomy on the jejunal side and a small gastrotomy on the gastric side are made to allow insertion of the two limbs of the linear cutter.

Once the device has been inserted, its direction is adjusted so that it is maintained parallel to the axis of the jejunum before being engaged and fired. The device is then removed, and the suture line is visualized through the enterotomy to ensure adequate hemostasis. The gastrotomy and enterotomy can be closed with a suture closure (in one or two layers) or with a linear stapler.

The other method involves partial transection of the stomach with a linear cutter followed by a handsewn anastomosis between the remaining open part of the stomach and the jejunum. In comparison with the aforementioned techniques, the gastrojejunal anastomosis is limited in length (see the images below).

Port placement for laparoscopic gastrectomy involves a 12-mm optical port at the umbilicus, a 5-mm epigastric port for liver retraction, two operating ports, and a right lateral port for gastric retraction. The approach for gastrectomy is similar to the open approach.

Initially, the lesser sac is entered by opening the gastrocolic omentum and the lesser omentum. The greater and lesser curvatures are cleared to the initial 2 cm of the duodenum before a stapler is fired to divide the duodenum. The greater curvature is freed to the point of proximal division, and the left gastric artery is identified and divided after retraction of the stomach superiorly and to the left. The specimen is extracted by extending one or both of the operating port incisions. Gastrojejunostomy is usually performed extracorporeally via the same incision.

A study by Takata et al reported the use of single-incision laparoscopic partial gastrectomy in 12 consecutive patients with gastric submucosal tumors.[22] In this procedure, three trocars were placed in the umbilical incision, and the lesion was mobilized and resected with endoscopic staplers. The authors found this approach to be a safe and practical alternative to conventional multiport laparoscopy in these patients, except for lesions originating in the lesser curvature and close to the cardia/pylorus.

Okumura et al, with the aim of minimizing the volume of resected tissue, developed a laparoscopic partial gastrectomy with seromyotomy (the "lift-and-cut" method) for gastric gastrointestinal stromal tumors (GISTs) and evaluated it in 28 patients.[23]  They reported an average operating time of 126 minutes (range, 65-302), an average blood loss of 10 mL (range, 0-200), and a median hospital stay of 7 days (range, 5-21). There were no intraoperative complications and no postoperative complications of Clavien-Dindo grade II or higher. At discharge, all 28 patients had a sufficient solid diet. No recurrence was reported at a median follow-up of 26.6 months (range, 6-54). 

Despite progressive improvements in technical skills and instruments, performance of intracorporeal gastrojejunal and jejunojejunal anastomoses has always been challenging. In a study that included 579 patients who underwent minimally invasive partial gastrectomy for gastric cancer at 13 high-volume institutions, Milone et al reported a technique for fashioning a handsewn intracorporeal enterotomy closure after a stapled anastomosis.[24] The following techniques for intracorporeal anastomoses were compared:

• Robotic vs laparoscopic approach
• Laparoscopic high-definition (HD) vs three-dimensional (3D) vs 4K technology
• Single-layer vs double-layer enterotomy closures
• For double-layer closures, layer-by-layer comparative analysis of continuous vs interrupted suture; presence vs absence of deep corner suture; and barbed vs braided vs nonbraided suture thread

In this study,[24]  rates of bleeding and leakage from gastrojejunal anastomosis were significantly lower in the double-layer group than in the single-layer group. Barbed suture thread, as compared with braided and nonbraided suture threads, was significantly associated with reduced intraluminal bleeding and leakage rates in both the first and the second layer of double-layer closures. Overall, the study found that double-layer enterotomy closures using barbed suture for the first and second layers resulted in the lowest intraluminal bleeding and anastomotic leak rates.

A review and meta-analysis (12 studies; N = 27,133) by Vellotti et al also demonstrated the security of a barbed suture in preventing leaks, bleeding, and stenosis after colorectal and bariatric surgery.[25]

Nonexposed endoscopic wall-inversion surgery (NEWS) is a newer technique for treating gastric cancer with partial resection that involves a full-thickness resection method using a combination of endoscopy and laparoscopic resection without transluminal access.[26]  It is a function-preserving approach that relies on accurate sentinel node mapping.

Robotic D2 lymph node dissection with distal gastrectomy has beren performed for for middle- or lower-third gastric cancer at centers with facilities for robotic surgery. Safety and feasibility have been well documented for cases in which distal subtotal gastrectomies with D2 lymph node dissection with partial omentectomy for gastric cancer have been performed robotically.[27]  

Robotic-assisted distal partial gastrectomy has also been reported in a patient with situs inversus partialis, a condition in which some organs of the patient's organs are inverted while others remain in their normal anatomic positions, leading to a surgically challenging procedure.[28]

Cost is a consideration with robotic-assisted surgery, and it has been addressed in some reports. El Chaar et al performed a cost comparison for length of hospitalization—along with factors such as operating time, supplies, 30-day complications, reoperations, and readmissions—for robotic-assisted sleeve gastrectomy (R-SG) and laparoscopic sleeve gastrectomy (L-SG).[29] They found that mean total costs for R-SG and L-SG were not significantly different ($5308.99 and $4918.88, respectively). However, operating time cost was significantly higher for L-SG than for R-SG ($1340 vs $112), and length of stay was slightly longer for L-SG as well (1.5 vs 1.4 d).

Intraoperative gastroscopy in laparoscopic partial gastrectomy

The role of intraoperative gastroscopy in laparoscopic partial gastrectomy was evaluated by Park et al in 1084 gastric cancer patients who underwent either intracorporeal or extracorporeal partial gastrectomy.[30]  Proximal margin positivity was compared in three patient groups, as follows:

• Intracorporeal group with intraoperative gastroscopy
• Intracorporeal group without intraoperative gastroscopy
• Extracorporeal group

Margin positivity was less in the intracorporeal group with intraoperative gastroscopy and was comparable with that in the extracorporeal group. Similarly, the number of patients with proximal resected margins smaller than 1 cm was less in the intracorporeal group with intraoperative gastroscopy and was comparable with that in the extracorporeal group. In cases of EGJ tumors, intraoperative gastroscopy prevented the occurrence of total gastrectomy and was found to be the only independent preventive factor.

Hybrid laparoscopic endoscopic partial gastrectomy

Ntourakis et al described hybrid laparoscopic endoscopic partial gastrectomy, a novel technique intended to address certain technical difficulties in the resection of GISTs by avoiding excessive removal of gastric tissue leading to dysfunction and reflux diseases.[31] The technique is based on the following three principles:

• First, the tumor is outlined and resected by using a combined method, without compromising the EGJ
• Second, the EGJ is exposed and distanced from the tumor by dissection
• Third, the lesser curvature is exposed by dissection, and the left gastric vessels are ligated at the incisura

The tumor is then tangentially resected with an endoscopic stapler, in a manner similar to a sleeve gastrectomy. The postoperative period was typically uneventful.

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 placing of running sutures through the anterior or posterior layer. In rare cases, intra-abdominal bleeding can result from slippage of ligatures[32] ; 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.[32]

Computed tomography (CT) with oral contrast can be used to evaluate doubtful leaks. Minor leaks can be managed with placement of a covered stent 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.[33]

Meticulous care and handling of the tissues are 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. In the absence of peritoneal signs, a conservative line of management can be adopted. 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 either early or 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 lightheadedness, palpitations, and crampy abdominal pain.[34]

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.[35, 36]  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.[37]  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.[38, 39, 40]  Afferent loop syndrome presents as periods of intense abdominal pain relieved with the vomiting of large volumes of bile. In cases of efferent loop obstruction, the vomitus consists of undigested food. Reoperation may be required if the obstruction is persistent and cannot be managed by conservative means.

A rare complication that has been documented is portal vein thrombosis or hepatic vein thrombosis after partial gastrectomy. This complication is suspected when there is an abnormal increase in procalcitonin combined with hyperthermia. It can develop a month or longer after surgery, as in two cases reported by Zhang et al.[41]