Overview
Definition:
Subtotal gastrectomy for distal gastric cancer involves the surgical removal of approximately two-thirds to three-quarters of the stomach, typically including the antrum and a portion of the body, while preserving the pylorus or a portion of the duodenum to facilitate reconstruction
This procedure is indicated for malignant neoplasms located in the distal part of the stomach.
Epidemiology:
Gastric cancer is a significant global health issue, ranking among the most common cancers worldwide
While incidence rates are declining in many Western countries, they remain high in East Asia, including India
Distal gastric cancers (antrum and pylorus) constitute a large proportion of all gastric malignancies
Age is a major risk factor, with peak incidence in individuals over 50 years.
Clinical Significance:
Subtotal gastrectomy for distal gastric cancer is a cornerstone of surgical treatment for localized disease, aiming for curative resection
Understanding its indications, surgical techniques, potential complications, and oncological principles is crucial for surgical residents preparing for DNB and NEET SS examinations, as it directly impacts patient outcomes and management strategies.
Indications
Surgical Indications:
Curative intent for T1-T3, N0-N2, M0 distal gastric adenocarcinoma
Early-stage gastric lymphoma
Benign gastric outlet obstruction with suspicion of malignancy
Unresectable but locally confined tumors where debulking is planned.
Staging Considerations:
Accurate preoperative staging (endoscopy with biopsy, CT scan, potentially EUS and laparoscopy) is paramount to determine resectability and choose appropriate surgical extent
Resection is generally favored for resectable disease within D1+ or D2 lymph node dissection parameters.
Patient Factors:
Patient's overall health status, comorbidities, and willingness to undergo major surgery
Age alone is not an absolute contraindication if the patient is fit for surgery.
Contraindications:
Distant metastases (M1 disease)
Extensive peritoneal carcinomatosis
Uncontrolled comorbidities precluding major surgery
Involvement of major vascular structures making en bloc resection impossible.
Preoperative Preparation
Diagnostic Workup:
Comprehensive history and physical examination
Upper GI endoscopy with biopsy for histopathological confirmation and grading
Contrast-enhanced CT scan of the abdomen and pelvis for staging and assessment of local invasion/metastasis
Blood tests including complete blood count, liver function tests, renal function tests, coagulation profile, and tumor markers (CEA, CA19-9)
Nutritional assessment and optimization, often with dietary counseling and possibly jejunal tube placement for nutritional support.
Informed Consent:
Detailed discussion with the patient and family about the nature of the disease, proposed surgery, extent of resection, reconstruction options, potential risks, complications, and alternatives
Emphasis on the oncological goal of R0 resection.
Anesthetic Considerations:
General anesthesia with appropriate monitoring
Multimodal analgesia
Fluid management
Considerations for potential blood loss and need for transfusion.
Procedure Steps
Approach:
Typically a midline laparotomy or a laparoscopic approach
Laparoscopic surgery is increasingly being adopted for early-stage distal gastric cancers.
Gastric Mobilization:
Careful dissection of the stomach from surrounding structures, including the pancreas, spleen (if indicated for nodal dissection), and omentum
Identification and preservation of the gastroepiploic vessels and short gastric arteries are crucial for blood supply to the remaining stomach.
Lymphadenectomy:
D1+ or D2 lymphadenectomy is essential for oncological clearance
D1 dissection includes lymph nodes along the lesser and greater curvature of the stomach, and nodes around the celiac axis
D2 dissection includes nodes along the left gastric artery, common hepatic artery, splenic artery, and para-aortic nodes.
Gastric Transection:
The stomach is divided at an appropriate level, usually proximal to the tumor, ensuring adequate margins
This can be done using an automated stapling device.
Reconstruction:
Billroth I (gastroduodenostomy) or Billroth II (gastrojejunostomy) are the common reconstruction methods
Roux-en-Y reconstruction may be preferred in select cases to reduce bile reflux and dumping syndrome
The choice depends on the extent of resection and surgeon preference.
Anastomotic Technique:
Secure and tension-free anastomosis, either hand-sewn or stapled, with meticulous attention to detail to prevent leaks.
Postoperative Care
Initial Management:
Close monitoring of vital signs, fluid balance, and urine output
Nasogastric tube decompression
Intravenous fluid resuscitation and electrolyte balance
Pain management with patient-controlled analgesia (PCA) or epidural analgesia.
Nutrition:
Gradual reintroduction of oral intake, starting with clear liquids and progressing to a soft diet as tolerated
Nutritional support via enteral feeding if oral intake is insufficient
Education on dietary modifications to manage dumping syndrome and malabsorption.
Monitoring For Complications:
Watch for signs of anastomotic leak (fever, tachycardia, abdominal pain, peritonitis), bleeding, ileus, pancreatitis, and pulmonary complications
Regular laboratory monitoring.
Mobilization And Discharge:
Early mobilization to prevent deep vein thrombosis and pulmonary complications
Discharge typically occurs when the patient is tolerating a diet, has adequate pain control, and has no signs of major complications, usually 7-14 days post-surgery.
Complications
Early Complications:
Anastomotic leak: can range from asymptomatic to life-threatening peritonitis
Intra-abdominal abscess
Bleeding from staple lines or vessels
Pancreatitis
Gastric stasis or outlet obstruction
Pulmonary complications (pneumonia, atelectasis)
Deep vein thrombosis and pulmonary embolism
Wound infection.
Late Complications:
Dumping syndrome (early and late): characterized by gastrointestinal and vasomotor symptoms after eating
Bile reflux gastritis
Marginal ulcer formation at the anastomosis
Nutritional deficiencies (e.g., vitamin B12, iron, calcium)
Weight loss
Afferent loop syndrome (in Billroth II)
Incisional hernia.
Prevention Strategies:
Meticulous surgical technique to ensure secure anastomosis and adequate blood supply
Prophylactic antibiotics
Use of stapling devices
Careful surgical planning for lymphadenectomy
Gradual dietary advancement
Patient education on diet and lifestyle modifications
Early recognition and prompt management of complications.
Prognosis
Factors Affecting Prognosis:
Stage of cancer (TNM staging) is the most critical factor
Histological type (e.g., Lauren intestinal type generally has a better prognosis than diffuse type)
Lymph node involvement (N stage)
Presence of vascular or perineural invasion
Completeness of surgical resection (R0 vs
R1/R2)
Patient's performance status and comorbidities
Age.
Outcomes:
For early-stage (Stage I) distal gastric cancer treated with subtotal gastrectomy and adequate lymphadenectomy, the 5-year survival rate can be high, often exceeding 70-80%
However, for advanced stages, prognosis is significantly poorer
Post-surgical quality of life is influenced by reconstructive techniques and management of post-gastrectomy syndromes.
Follow Up:
Regular follow-up visits are crucial to monitor for recurrence and manage long-term sequelae
This typically involves clinical examination, laboratory tests (including tumor markers), and periodic imaging (CT scans)
Endoscopy may be performed to assess the anastomosis and rule out metachronous lesions
Follow-up schedules vary but often include monthly visits for the first year, then quarterly, biannually, and annually thereafter for 5 years.
Key Points
Exam Focus:
Indications for subtotal vs
total gastrectomy
Principles of D1 vs
D2 lymphadenectomy
Reconstruction techniques (Billroth I, Billroth II, Roux-en-Y) and their implications
Common early and late post-gastrectomy complications and their management
TNM staging and its impact on prognosis.
Clinical Pearls:
Ensure adequate proximal margin for tumor clearance
Preserve short gastric vessels to maintain blood supply to the residual stomach
Meticulous hemostasis is vital
Consider reconstruction to minimize bile reflux
Patient education on post-gastrectomy diet is paramount for functional recovery.
Common Mistakes:
Inadequate lymphadenectomy leading to local recurrence
Insufficient proximal margin
Over-reliance on one type of reconstruction without considering patient factors
Underestimation of post-gastrectomy syndromes
Delayed diagnosis and treatment of complications like anastomotic leak.