Continuing Education Activity

Gastric resection remains the preferred surgical treatment option for many diseases of the stomach including malignancy, peptic ulcer disease, and bariatric procedures. Minimally invasive gastrectomy has been shown to have decreased hospital length of stay, fewer perioperative complications, and less intraoperative bleeding than open procedures. This activity outlines the preparation and complications of gastric resection, as well as highlights the role of the interprofessional team in evaluating and managing patients who require gastric resection.

Objectives:

• Identify the indications for gastric resection.

• Outline common complications of gastric resection.

• Summarize the evaluation, planning, and techniques involved in gastric resection.

• Explain the importance of improving care coordination among the interprofessional team to improve outcomes in patients with gastric carcinoma requiring gastric resection.

Introduction

Gastric resection remains the preferred surgical treatment option for many benign and malignant diseases of the stomach.[1] Gastric cancer is the fifth most common malignancy worldwide in which gastric resection or total gastrectomy remains the only strategy for long-term survival and hope for a cure.[2][3][4] Subtotal gastrectomy is the removal of 70-80% of the distal stomach, whereas total gastrectomy is the removal of the entire stomach, including the pylorus.

Despite a steady decline in the incidence and mortality of gastric carcinoma observed over the last century, the absolute number of cases increases annually due to an aging population.[4][5] Early diagnosis of gastric carcinoma is very uncommon, and the incidence of nodal metastases is high.[6] Lymphatic spread is the most important prognostic factor in gastric cancer; therefore, adequate lymphadenectomy is required for curative resection as well as staging.[5] 

Gastric cancers can be divided into the intestinal type and diffuse type. The most common underlying etiology of intestinal-type carcinoma is Helicobacter pylori infection, which can develop into atrophic gastritis with intestinal metaplasia.[7] Diffuse type carcinoma is characterized by marked fibrosis and early invasion into the submucosa.[7] Risk factors for gastric carcinoma include genetics (CDH1 gene), H. pylori infection, gastric ulcers, gastroesophageal reflux disease (GERD), tobacco or alcohol use, diet, and chemical exposure.[4]

This article will discuss the relevant anatomy, indications, contraindications, procedure details, and complications associated with gastric resection.

Anatomy and Physiology

A thorough understanding of the anatomy, vascular supply, and lymphatic drainage of the stomach is paramount to successful gastric resection.

Stomach Anatomy  

• The stomach can be divided into four parts: the cardia, body, antrum, and pylorus.
• Gastrocolic Ligament: a portion of the greater omentum that connects, the greater curvature of the stomach to the transverse colon, and forms part of the anterior wall of the lesser sac.
• Gastrosplenic ligament: a portion of the greater omentum that connects, the greater curvature of the stomach to the hilum of the spleen, contains the left gastroepiploic and short gastric arteries.
• Gastrohepatic ligament: a peritoneal attachment that connects the liver to the lesser curvature of the stomach and forms part of the anterior wall of the lesser sac; contains the right and left gastric arteries.
• Gastrophrenic ligament: a peritoneal attachment that connects the diaphragm to the superior portion of the stomach.

Vascular Supply

• Celiac Trunk: originates from the abdominal aorta and gives off three major branches: the left gastric, common hepatic, and splenic arteries.
• Left Gastric Artery: arises from the celiac trunk, runs along the superior portion of the lesser curvature of the stomach, and anastomoses with the right gastric artery.
• Right Gastric Artery: arises from the proper hepatic artery, runs along the inferior portion of the lesser curvature of the stomach, and anastomoses with the left gastric artery.
• Left Gastroepiploic Artery: arises from the splenic artery, runs along the superior portion of the greater curvature of the stomach, and anastomoses with the right gastroepiploic artery.
• Right Gastroepiploic Artery: arises from the gastroduodenal artery, runs along the inferior portion of the greater curvature of the stomach, and anastomoses with the left gastroepiploic artery.
• Short Gastric Arteries: a group of short arteries that originate from the splenic artery and left gastroepiploic artery to supply the greater curvature of the stomach.

Lymphatic Drainage

• Lymphatic drainage of the stomach is anatomically elaborate and includes 16 regional lymphatic stations.
• Lymph node stations are categorized as N1, N2, or N3 groups with respect to their location to the primary tumor[5][6]
  • N1 Nodes - perigastric lymph nodes (stations 1-6)
  • N2 Nodes - lymph nodes along the main vessels originating from the celiac trunk, including the left gastric, common hepatic, and splenic artery (stations 7-11)
  • N3 Nodes - lymph nodes of the hepatoduodenal ligament (station 12), retropancreatic region (station 13), and root of the mesentery (station 14)
  • N4 Nodes - lymph nodes along the middle colic vein (station 15) as well as the para-aortic lymph nodes (station 16)
• Lymph node dissection is characterized by the lymph node stations removed. A D1 lymphadenectomy includes stations 1-6, and a D2 lymphadenectomy includes stations 1-6 as well as stations 7-11.

Indications

The most common indications for gastric resection include:[1]

• Malignancy - adenocarcinoma, gastrointestinal stromal tumors (GIST), neuroendocrine neoplasms, signet ring cell gastric cancer, and hereditary diffuse gastric cancer (CDH1 mutation carriers)
• Peptic ulcer disease - refractory gastric ulcer disease and associated sequelae including bleeding, perforation, or stricture
• Bariatric procedures - Roux-en-Y gastric bypass, sleeve gastrectomy, or gastric banding

Subtotal distal gastrectomy is considered the gold standard for tumors of the gastric body or antrum in which a 4-6 cm proximal margin can be obtained while maintaining an adequately sized remnant pouch.[8] Total gastrectomy is indicated for tumors involving the entire or proximal stomach, signet ring cell gastric cancer (diffuse submucosal spread), or hereditary diffuse gastric cancer (multifocal pattern).[8]

Contraindications

Absolute contraindication to gastric resection includes any patient who is too unfit for general anesthesia. Relative contraindications to gastric resection include patients who are elderly, have an advanced cardiopulmonary failure, or decreased life expectancy due to other chronic conditions.

Total gastrectomy is contraindicated when wide negative margins (4 to 6 cm) can be achieved with partial gastrectomy, as partial gastrectomy has a significantly improved safety and long-term functional outcome profile, especially in patients with advanced age, malnutrition, and extensive comorbidities.[8]

Equipment

A standard open or laparoscopic abdominal operative tray is essential to the surgeon’s success in performing this procedure. Basic equipment such as surgical drapes, scalpels, and electrocautery should be included. For open procedures, a self-retaining table-mounted retractor such as a Bookwalter retractor system is helpful. For laparoscopic procedures, CO2 gas insufflation tubing, trocars, a 30-degree laparoscope with a light source, and a monitor are required.

Frequently used instruments for both open and laparoscopic procedures include suction irrigator, bowel graspers, liver retractor, scissors, ultrasonic dissector (harmonic scalpel), and vessel sealing device. A linear GIA or circular EEA stapler may be used depending on the type of gastric resection and reconstruction technique performed.

Personnel

In order to perform a gastric resection or total gastrectomy, the surgeon should have adequate experience in foregut and oncological surgery. Essential personnel is the standard surgical team, including the operating surgeon, first assistant, anesthesiologist, scrub technician, and circulating nurse.

Preparation

Unfortunately, most patients with gastric carcinoma are diagnosed at advanced stages. Symptoms may include weight loss, cachexia, anorexia, early satiety, dyspepsia, gastric outlet obstruction, or malnutrition. Work up for gastric cancer involves a variety of diagnostic tests that stratify which patients are candidates for gastric resection. Routine laboratory tests should be obtained, including baseline hemoglobin, platelet count, and complete metabolic profile. Albumin and prealbumin are serum markers that can be used to assess nutritional status.

Diagnostic evaluation begins with an esophagogastroduodenoscopy (EGD) if the gastric neoplasm is suspected. EGD provides a histopathologic diagnosis, as well as the location and the extent of the tumor.[2] Endoscopic ultrasound (EUS) is used to assess for tumor depth (T stage) and possible nodal involvement.[2] CT scan of the chest, abdomen, and pelvis with oral and intravenous contrast should be obtained to evaluate for the presence of distant metastatic disease or bulky lymphadenopathy. Positron tomography (PET) scan is an additional imaging modality that can be used as an adjunct for staging.[2]

An interprofessional approach should be taken to determine surgical resectability, preoperative planning, and the role of neoadjuvant chemotherapy or radiation. A careful review of the patient’s comorbidities is required for medical optimization as well as an assessment of the patient’s performance status and ability to tolerate surgery. Additionally, any modifiable risk factors must be addressed prior to surgical intervention, such as preoperative smoking cessation, which has been reported to improve outcomes after gastrectomy for malignancy.[1]

Technique or Treatment

Gastric resection may be performed using an open, laparoscopic, or robotic-assisted approach. Randomized controlled trials comparing laparoscopic and open gastrectomy have shown oncologic equivalency and demonstrated favorable outcomes in postoperative recovery with minimally invasive approaches.[2] Minimally invasive gastrectomy has been shown to have decreased hospital length of stay, fewer perioperative complications, and less intraoperative bleeding than open procedures.[2][3] Considerations for open gastrectomy include surgeon preference, increased operative difficulty, port site recurrence, and decreased adequacy of lymph node dissection.[9] 

For all techniques, the patient is placed on the operating room table in the supine position and prepped and draped in the usual sterile fashion. Preoperative antibiotics are given, and a nasogastric tube is placed for gastric decompression. The outline below describes the key steps for gastric resection.[2][3][8]  

Step 1: Staging Laparoscopy and General Inspection  

Diagnostic laparoscopy should be performed initially to rule out the occult metastatic disease of the liver or peritoneum. If no evidence of grossly metastatic disease is seen, the surgeon can proceed with gastric resection. A liver retractor may be placed to mobilize and retract the left lobe of the liver.

Step 2: Entry into the Lesser sac and Mobilization of the Greater Curvature of the Stomach 

The patient is placed in a slightly reverse Trendelenburg position, and the division of the gastrocolic ligament provides entry into the lesser sac. Care should be taken to avoid damage to the transverse colon mesentery and vasculature. The splenic flexure is dissected, and the left gastroepiploic artery and short gastric vessels are divided. Lymph nodes from the splenic hilum are left en bloc to be taken with the specimen. Omentectomy is then carried out along the transverse colon laterally towards the liver, and the right gastroepiploic vessels are divided. Dissection is carried down to approximately 2 cm distal to the pylorus. 

Step 3: Mobilization of the Lesser Curvature of the Stomach and Duodenum  

The lesser curvature of the stomach is mobilized toward the esophagus and the right crus of the diaphragm. The gastrohepatic ligament is divided, and care should be taken to avoid damage to an accessory right hepatic artery. The left and right gastric vessels are divided. Lymphatic tissue following the common and proper hepatic arteries is mobilized and taken en bloc with the specimen. For total gastrectomy, dissection of the intraabdominal esophagus is performed. Pericardial lymph nodes (stations 1 and 2) are dissected en bloc with the specimen. The gastrohepatic omentum must be divided at the level of the esophageal hiatus. 

Step 4: Lymphadenectomy  

A D2 nodal dissection is a gold standard for gastric carcinoma. Stations 1-7 are perigastric nodes that are taken en block with the gastric specimen. Lymphadenectomy continues along the proper hepatic artery and is carried along the common hepatic artery (station 8) toward the celiac axis (station 9) and splenic artery (station 11p and 11d). Dissection is then carried down to the hepatoduodenal ligament to harvest associated lymph nodes. (station 12a)

Step 5: Gastric Transaction                          

The duodenum is divided using a linear GIA stapler after the nasogastric tube is removed. The duodenum is taken en bloc with the inferior and superior pyloric nodes (stations 5 and 6). Once the tumor is identified, the stomach or distal esophagus is transected with a linear GIA stapler so that adequate oncologic proximal margins of 4-6 cm are obtained.

Step 6: Reconstruction

There are various reconstruction techniques that have been described for gastric resection. For subtotal gastrectomy, reconstruction with Billroth 1 gastroduodenostomy, Billroth 2 gastrojejunostomy, or Roux-en-Y gastrojejunostomy may be performed. For total gastrectomy, reconstruction with a Roux-en-Y esophagojejunostomy or a Hunt-Lawrence jejunal pouch may be performed.[8] Randomized controlled trials have shown Roux-en-Y reconstruction has a decreased rate of long-term postoperative outcomes following gastric resection.[10]

Roux-en-Y Reconstruction - Jejunum at a distance 30 to 50 cm from the ligament of Treitz is divided using a linear GIA stapler to create the Roux limb proximally and the biliopancreatic limb distally. Jejunojejunostomy is made 60-70 cm along the Roux limb. The antimesenteric borders of the biliopancreatic limb and Roux limb are aligned, and enterotomies are made for the linear GIA stapler. The anastomosis is completed using a TA stapler. The mesenteric defect is closed with an absorbable suture to prevent internal hernias. The Roux limb is brought up to the proximal stomach or esophagus in an antecolic or retrocolic fashion. Stapled or hand-sewn end-to-end esophagojejunostomy or gastrojejunostomy anastomosis is created. A water-bubble test can be performed to rule out a leak. A water-soluble upper GI contrast study can be performed on postoperative day 5 to assure the integrity of the anastomosis before initiation of oral intake.[8]

Step 7: Optional Distal Feeding Tube Placement  

Additional consideration should be given to patients with preoperative weight loss or risk factors for complicated or delayed postoperative recovery. In such cases, a jejunostomy feeding tube may be considered and placed in the distal jejunum in a Stamm or Witzel fashion. The placement of a feeding jejunostomy tube is not routinely recommended but may be required in patients with severe preoperative nutritional deficiencies or if adequate nutrition post-operatively is a concern.[2]

Complications

As with any surgical procedure, there is a risk of bleeding, infection, and damage to surrounding structures. High-risk patients may be at increased risk for complications that may result in significant morbidity or even mortality. Tobacco use, preoperative malnutrition, total gastrectomy, non-malignant indication for resection, and blood transfusions have been linked to increased risk for morbidity.[1]

Complications can be divided into early (days to weeks) or late (after 6 weeks):[11]

Early Complications

• Anastomotic Leak
• Bowel obstruction or post-operative Ileus
• Duodenal stump blowout
• Delayed gastric emptying

Late Complications

• Bile reflux gastritis
• Dumping syndrome
• Afferent and efferent limb syndrome
• Malnutrition and nutritional deficiencies
• Internal hernia or Peterson hernia
• Anastomotic stricture
• Marginal ulcer
• Cancer recurrence

The most common post-gastrectomy complications following gastric resection include nutritional deficiencies, dumping syndrome, small gastric remnant, post-vagotomy diarrhea, delayed gastric emptying, afferent or efferent loop syndrome, roux stasis, and bile reflux gastritis.[12] 

• Internal Hernias are a known cause of acute abdominal pain in patients with gastric resection and Roux-en-Y reconstruction. Three types of trans-mesenteric hernias commonly occur in these patients. Transmesocolic hernias involve herniation through the surgical defect in the transverse mesocolon through which the alimentary limb descends. Peterson’s hernia is a herniation through the potential space between the Roux limb mesentery and the mesocolon, which occurs behind the alimentary limb. Lastly, the bowel can herniate through the small bowel mesentery, particularly at the jejunostomy site.[11]

• Dumping Syndrome is characterized by a constellation of gastrointestinal and vasomotor symptoms in response to the rapid gastric emptying of hyperosmolar contents into the proximal intestine. Early dumping begins within 30 minutes of food consumption and manifests with both gastrointestinal and vasomotor symptoms, including abdominal pain, diarrhea, bloating, nausea, flushing, palpitations, diaphoresis, tachycardia, syncope, and hypertension. Late dumping occurs 2 to 4 hours after a meal and consists primarily of vasomotor symptoms associated with hypoglycemia. Dumping syndrome is treated primarily by diet modification, medical treatment with somatostatin analogs, or surgical intervention for refractory cases.[12] 

• Bile Reflux Gastritis is the result of chronic exposure of the gastric remnant to biliopancreatic secretions caused by the loss of the pylorus. Symptoms include epigastric pain, nausea with vomiting, and pain that is only partially associated with meals. Diagnosis can be made by endoscopy findings of bile and inflammation in the distal stomach or HIDA scan showing pooling of bile in the stomach or esophagus in severe cases. Surgical correction is the mainstay of treatment and consists of conversion to Roux-en-Y gastrojejunostomy with at least a 60 cm Roux limb to divert biliopancreatic contents away from the gastric remnant.[12]

• Afferent and Efferent Loop Syndromes are well-established complications of gastric resection. Afferent loop syndrome is an uncommon obstruction that may result from the internal hernia, marginal ulceration, adhesions, recurrent cancer, or intussusception in patients with Billroth II gastrectomy. Symptoms include immediate postprandial pain and cramping, followed by vomiting that completely relieves symptoms. Acute afferent loop syndrome that occurs 1 to 2 weeks postoperatively is critical to detect as it can lead to a duodenal stump leak. Efferent loop syndrome is a mechanical obstruction at the gastrojejunostomy that may result from anastomotic stricture, marginal ulceration, recurrent cancer, or adhesions. Symptoms include bilious emesis or delayed gastric emptying.[12]

Clinical Significance

Gastric resection remains the preferred surgical treatment option for many diseases of the stomach, including malignancy, peptic ulcer disease, and bariatric procedures. Minimally invasive gastrectomy has been shown to have decreased hospital length of stay, fewer perioperative complications, and less intraoperative bleeding than open procedures. Gastric resection is often complicated by post-gastrectomy syndromes, including internal herniation, dumping syndrome, bile reflux gastritis, and afferent/efferent loop syndromes.

Enhancing Healthcare Team Outcomes

An interprofessional approach is crucial to the success of gastric cancer patients and should involve collaboration between primary care physicians, surgical oncologists, radiation oncologists, and oncologic surgeons to determine surgical resectability, preoperative planning, and the role for neoadjuvant chemotherapy or radiation. Because gastric cancer may manifest in a variety of histologic, anatomic, and genetic patterns, a customized treatment plan for each patient leads to the best outcomes.[2]

Similarly, for patients who undergo gastric resection for weight loss, an interprofessional approach is paramount to their success and should include a bariatric surgeon, gastroenterologist, primary care physician, dietician, nursing supervisor, and mental health professionals. Due to the physiologic and psychological changes that occur with bariatric surgery, these patients require long-term follow-up and management.

Nursing, Allied Health, and Interprofessional Team Interventions

Communication and coordination between the interprofessional team are required to optimize gastric resection outcomes as well as patient morbidity and mortality. Nursing staff must communicate effectively during handoff to report a history of gastric resection and associated comorbidities. Specialized nurses should be available to provide support and education. Understanding complications such as bowel obstruction, anastomotic leak, post-operative bleeding, duodenal stump blowout, delayed gastric emptying, and malnutrition as well as identifying patients complaining of acute abdominal pain, nausea, or vomiting can prompt nurses to call surgical services sooner.

Nursing, Allied Health, and Interprofessional Team Monitoring

Nursing care is crucial in monitoring for evidence of surgical complications post-operatively. Nursing staff should be able to identify signs of the following life-threatening complications post gastric resection:

• Bowel Obstruction - abdominal pain, tachycardia, hypertension, abdominal distention, nausea, vomiting, inability to pass gas, or have a bowel movement.
• Anastomotic Leak - acute abdominal pain, tachycardia, fever, decreased urine output, leukocytosis, change in drain output color or volume, altered mental status. 
• Post-operative Bleeding- abdominal pain, tachycardia, hypotension, drop in hemoglobin, decreased urine output, increased sanguineous drain output.