Overview
Definition:
Proximal gastrectomy is a surgical procedure involving the removal of the upper portion of the stomach, including the cardia and fundus, while preserving the antrum and pylorus
Double tract reconstruction refers to a technique that creates two distinct pathways for food passage: one from the esophagus to the stomach remnant (esophagojejunostomy or esophago-gastric anastomosis) and another from the stomach remnant to the duodenum (gastrojejunostomy)
This aims to maintain continuity and reduce the incidence of dumping syndrome and bile reflux compared to traditional reconstructions.
Epidemiology:
Proximal gastrectomy is indicated for tumors located in the upper third of the stomach, including the cardia and fundus
Incidence varies by geographic region, with higher rates in East Asia
Benign conditions like achalasia or leiomyomas in the proximal stomach may also necessitate this procedure
The choice of reconstruction is influenced by surgeon preference and patient factors, with double tract techniques gaining popularity for specific indications.
Clinical Significance:
This procedure is crucial for managing early-stage gastric cancers in the proximal stomach and certain benign conditions, aiming for oncological safety while preserving digestive function and quality of life
Understanding the surgical technique, its indications, potential complications, and reconstruction methods is vital for surgical residents preparing for DNB and NEET SS examinations, as it represents a significant advancement in gastric surgery.
Indications
Gastric Cancer:
Resectable adenocarcinoma or other malignant neoplasms confined to the proximal stomach (cardia, fundus, upper body)
Tumors with limited submucosal invasion and no distant metastasis are ideal candidates
Minimal invasion into the distal stomach or duodenum is acceptable for this technique.
Benign Conditions:
Selected cases of achalasia with significant esophageal involvement, leiomyomas or other benign tumors of the gastric fundus, or severe peptic ulcer disease with intractable symptoms unresponsive to medical management, located proximally.
Surgical Goals:
Complete tumor resection with adequate margins (oncological safety) while preserving gastric reservoir function and minimizing post-operative morbidity, especially dumping syndrome and bile reflux.
Preoperative Preparation
Patient Assessment:
Thorough evaluation of cardiopulmonary status, nutritional status, and comorbidities is essential
Endoscopic evaluation, biopsy, and staging investigations (CT scan, EUS) are mandatory to confirm resectability and tumor extent.
Nutritional Support:
Preoperative nutritional optimization, including high-protein diet and micronutrient supplementation, may be beneficial for patients with malnutrition or significant weight loss.
Informed Consent:
Detailed discussion with the patient regarding the procedure, its risks, benefits, potential complications, and alternative treatment options, including the specifics of the double tract reconstruction.
Procedure Steps
Gastric Mobilization:
Radical lymphadenectomy (D1+ or D2 dissection depending on tumor stage) is performed
The proximal stomach is mobilized from surrounding structures, and the esophagus is transected.
Gastric Antrum Preservation:
The distal stomach, including the antrum and pylorus, is preserved
The duodenum is transected distal to the pylorus.
Double Tract Reconstruction:
The "double tract" is created by first performing an esophagojejunostomy (e.g., Roux-en-Y or omega loop) to connect the esophagus to the jejunum
Subsequently, a gastrojejunostomy is created between the preserved gastric remnant and a limb of the jejunum, bypassing the duodenum
The specific configuration may vary (e.g., anterior or posterior gastrojejunostomy).
Anastomotic Techniques:
Suturing or stapling devices are used for anastomoses
Careful attention to tension-free anastomosis and adequate blood supply to the jejunal loops is critical.
Postoperative Care
Monitoring:
Close monitoring of vital signs, fluid balance, pain management, and nasogastric tube output
Early detection of anastomotic leaks or bleeding is paramount.
Nutritional Management:
Gradual reintroduction of oral intake, starting with clear liquids and progressing to soft and then regular diet as tolerated
Nutritional support, potentially including parenteral nutrition initially, is crucial
Emphasis on small, frequent meals and avoiding trigger foods.
Early Mobilization:
Encouraging early ambulation to prevent deep vein thrombosis and pneumonia
Wound care and pain control are integral to recovery.
Complications
Early Complications:
Anastomotic leak (esophagojejunal or gastrojejunal), bleeding, intra-abdominal abscess, pancreatitis, chylothorax, and ileus
Early identification and management are key.
Late Complications:
Dumping syndrome (early and late), bile reflux gastritis, marginal ulcer formation, afferent loop syndrome, nutritional deficiencies (e.g., B12, iron), weight loss, and recurrent disease
Careful dietary modification and medical management are often required.
Prevention Strategies:
Meticulous surgical technique, appropriate lymphadenectomy, tension-free anastomoses, prompt diagnosis and management of leaks, and comprehensive postoperative nutritional and dietary guidance are essential for preventing complications.
Key Points
Exam Focus:
Indications for proximal gastrectomy, comparison with total gastrectomy, rationale behind double tract reconstruction, specific anastomotic techniques used, and common post-operative complications like dumping syndrome and bile reflux.
Clinical Pearls:
Ensure adequate lymphadenectomy for oncological clearance
The choice of reconstruction technique should balance oncological goals with functional outcomes
Aggressive management of anastomotic leaks is critical
Patient education on dietary modifications post-reconstruction is vital for long-term well-being.
Common Mistakes:
Inadequate lymphadenectomy, compromised blood supply to anastomotic sites, misdiagnosis of tumor extent leading to inappropriate resection, or delayed recognition and management of anastomotic leaks or other complications.