Description: Total or partial gastrectomy is performed most commonly for gastric cancers (adenocarcinomas or gastrointestinal stromal tumors [GIST]) and will include omentectomy, lymph node dissection, and occasionally resection of adjacent organs such as the spleen or colon, depending on the pathology, location, and extent of the tumor. Historically there have been other indications for gastrectomy such as ulcer disease, Zollinger-Ellison syndrome, and uncontrollable hemorrhagic gastritis, but these operations are rarely if ever performed for those indications in current surgical practice. Rarely patients who suffer from severe and uncontrollable gastroparesis postgastric surgery may require total gastrectomy.

In a gastric resection, the abdomen is entered through an upper midline incision, and the lateral segment of the left lobe of the liver is retracted anteriorly and to the patient’s right, exposing the esophagogastric junction. The omentum is taken off of the colon and left attached to the greater curvature of the stomach. The spleen may be removed if involved by tumor or if an unplanned splenic injury occurs. The vessels to the stomach are individually ligated and divided. The short gastric vessels high on the greater curvature are difficult to reach and are a source of potential blood loss. This is also the most likely time that a splenic injury may occur by traction or tearing of the capsule while exposing the short gastric arteries. Currently most surgeons are using various devices to ligate the arteries, and these occasionally have a technical failure, which can result in blood loss. In the lesser sac, the left gastric artery as it branches from the celiac axis and vein needs to be divided and can be another point of potential unexpected blood loss. A total gastrectomy is performed for more proximal cancers and a partial resection for distal cancers. In all cases of gastric cancer, the antrum and pylorus are resected, leaving a duodenal stump and requiring gastroenterostomy to restore intestinal continuity. One area of potential complication when the stomach is resected is the accidental stapling of the gastric tube, which remains undetected until too late. To prevent this, the tube should be pulled back well into the esophagus, preferably with manual confirmation by the surgeon that the tube is no longer present in the stomach.

After completion of the gastric resection, reestablishment of intestinal continuity is performed. In the case of a total gastrectomy, a Roux limb of jejunum will be brought up to the distal esophagus; in partial gastrectomies a Roux limb or loop of jejunum (Billroth II) is connected to the remnant stomach. With a Roux limb the jejunum is divided just beyond the ligament of Treitz, and the distal end is brought up through a hole in the mesentery of the colon and anastomosed to the esophagus or stomach. Intestinal continuity is established by anastomosing the biliary pancreatic limb of the proximal jejunum to the Roux limb of jejunum, approximately 60 cm distal to the anastomosis with the esophagus. A drain is then placed near the closed end of the duodenum. The anastomosis can either be stapled or hand sewn depending on the preference of the surgeon. At completion of the anastomosis a NG tube can be advanced across the proximal anastomosis, and the abdomen is irrigated. A number of surgeons will then place a feeding jejunostomy tube into the jejunum, which adds a few minutes to the procedure prior to fascial closure. Total gastrectomy traditionally has been associated with a morbidity and mortality out of proportion to the operation’s apparent magnitude. This is most likely a consequence of the patient’s underlying condition, which often includes advanced malignancy and, almost invariably, some degree of malnutrition. Venous thromboembolism (VTE) is a significant concern in these patients because of their increased hypercoagulable state from the cancer and an operation of greater than 1 h in duration. Patients undergoing gastric resection should receive sequential compression devices on the lower extremities and subcutaneous heparin thromboprophylaxis.

Variant procedure or approaches: Occasionally a gastric cancer can have extensive local involvement of adjacent organs requiring an en bloc resection of the stomach in addition to the colon, spleen, or pancreas. For certain distal gastric cancers a combined gastric resection with a Whipple procedure (pancreaticoduodenectomy) may be necessary. The need for en bloc resection of the stomach in combination with other organs increases the complexity of the surgery, risk of blood loss, and postoperative morbidity and mortality. In general, exposure for a partial gastrectomy is similar to, but less extensive than, that required for a total gastrectomy. The same cancer principles are followed for either a partial or total resection including > 5 cm proximal margin, lymphadenectomy, and omentectomy. A partial gastrectomy is a simpler resection. The blood supply to the distal stomach is divided, and the duodenum is divided just beyond the pylorus. The body of the stomach is divided with a stapler (care should be taken to not staple the gastric tube) at a level appropriate for the pathology. Reconstruction after resection may be either to the duodenum (Billroth I), loop of jejunum (Billroth II; Fig. 7.2-1), or a Roux-en-Y limb of jejunum.
The anastomoses may be stapled or sewn; then the abdomen is closed. Like many operations, gastric resections are increasingly performed using minimally invasive techniques. The laparoscopic approach has the advantages of diminished postoperative pain and quicker recovery, but longer operative time requires a pneumoperitoneum and reverse Trendelenburg positioning.

Tumors (usually adenocarcinoma) of the gastroesophageal (GE) junction are increasing in frequency and may be of either gastric or esophageal origin. If the tumor is associated with Barrett’s esophagus (intestinal metaplasia in the esophagus, seen on endoscopy), surgery consists of either an Ivor Lewis with esophagogastric anastomosis in the
mediastinum (combined abdominal and transthoracic approach) or transhiatal esophagectomy (see p. 492) with gastroesophageal anastomosis in the neck. Bulky GE junction tumors that encompass the upper stomach will limit the extent of esophageal resection if stomach pull-up is used. Postop pain can be severe, and most patients will benefit from continuous epidural analgesia.

Usual preop diagnosis: Total gastrectomy: gastric cancers, GIST, gastroparesis; partial gastrectomy: gastric cancer; GIST, gastric ulcers.

See Anesthetic Considerations following Operations for Peptic Ulcer Disease, p. 509.

Description: Patients who present with gastric or duodenal perforations require emergency surgery because they usually have peritonitis at presentation. The primary reason for perforations that present to the emergency room is ulcer disease most likely from Helicobacter pylori infection or from NSAID use. Another cause of gastric perforation is trauma, but that is not in the scope of this section. Simple closure with an omental patch, also called a Graham’s patch, is the most commonly performed operation to treat a duodenal perforation. It is unusual to perform a definitive ulcer operation unless the patient has failed medical treatment regimens aimed at eradication of H. pylori infection along with proton pump inhibitors to suppress acid production.

Duodenal ulcers are most often caused by a benign process whereas gastric ulcer perforation without a history of NSAID use is suspicious of a malignant process. For this reason, surgeons may elect to treat a perforated gastric ulcer by resection. Occasionally in patients who have failed maximal medical management of their peptic ulcer disease and who are not systemically ill at the time of operation, some surgeons may perform vagotomy and pyloroplasty or highly selective vagotomy at the time of closure of the perforation.

Many surgeons routinely perform simple closure with Graham’s patch via a laparoscopic approach. This requires a few trocars and a pneumoperitoneum and can be combined with abdominal washout and irrigation. If an open approach is used, an upper midline incision is used. The liver is retracted superiorly and the area of perforation identified. An NGT to suction minimizes ongoing leakage from the perforation and decompresses the stomach. Perforation of the stomach may be handled either by resection (see Gastric Resections, p. 502) or by biopsy and simple suture closure. Perforation of the duodenum is usually repaired by simple suturing of the site. Omentum often is used to buttress (Graham’s patch) the area of closure of the stomach or duodenum. The abdomen is irrigated and closed.

Variant procedure or approaches: In certain patients, nonoperative management of perforated ulcer may be appropriate if they have had an upper GI study that shows an ulcer cavity and no extravasation. These patients are treated with NG decompression, antibiotics, and proton pump inhibitors. In general, this has a relatively high likelihood of success if the candidates are chosen well.

Usual preop diagnosis: Free air under diaphragm and peritonitis, perforated peptic ulcer

See Anesthetic Considerations following Operations for Peptic Ulcer Disease, p. 509.

Description: Gastric ulcers are commonly associated with advanced age, and patients often have other medical problems, particularly cardiovascular and pulmonary. Two developments have transformed peptic ulcer disease (PUD) from a common surgical problem to a rare surgical emergency (e.g., perforation and bleeding typically in the chronically ill, hospitalized patient). These developments are (1) inhibitors of gastric acid secretion, and (2) understanding the role of gastric overgrowth by Helicobacter pylori. The first antisecretory drugs were H₂-receptor antagonists (e.g., cimetidine, ranitidine); however, proton pump inhibitors (PPIs) have proven to be more effective. The treatment of H. pylori consists of 14 d of a PPI, plus antibiotic therapy. The medical management of PUD has so revolutionized the treatment of this disease that few current graduating residents have seen or done the surgical procedures described below. All operations for PUD require exposure of the upper abdomen and may be performed using either an upper midline or a long, right subcostal incision. The choice of surgical procedure depends on a number of considerations, including whether it is performed emergently or electively; the reason for performing the procedure (common factors include bleeding, perforation, intractability, or gastric outlet obstruction); duration of symptoms; condition of the patient; and experience of the surgeon.

Vagotomy and antrectomy (V&A): This is the most extensive of the operations performed for PUD and generally is reserved for healthy patients with intractable symptoms. The esophageal hiatus is exposed either by taking down the lateral segment of the left lobe of the liver and reflecting it to the patient’s right or by retracting this segment of the liver superiorly to gain exposure. The phrenoesophageal ligament is divided, and the anterior and posterior vagus nerves (there may be more than one of each) are identified by feel. Division of all vagal trunks at the esophageal hiatus is performed. The blood supply to the antrum is then divided, by dividing the right gastric and gastroepiploic vessels first. The gastrohepatic ligament is divided and the stomach elevated off its attachments to the transverse colon. The gastric antrum is resected, leaving the duodenum just beyond the pylorus and dividing the stomach just above the junction of the body with the antrum. Reconstruction may be as a Billroth I (stomachto-duodenum) or Billroth II (stomach-to-jejunal loop; Fig. 7.2-1). The anastomosis may be stapled or hand sewn. Drains are not commonly used if a Billroth I is performed, but may be used in Billroth II because of the concern for a leak from the duodenal stump.

Vagotomy and pyloroplasty (V&P): This is the most commonly performed operation for PUD in the United States and is especially common for emergency operations. It is generally accepted to be simpler and safer to perform than V&A, but not as effective at preventing recurrence of ulcer disease. The abdominal incision and exposure of the hiatus to perform a vagotomy is the same as for V&A. After division of both vagal trunks (Fig. 7.2-2), a longitudinal incision is made through the pylorus. The incision is then sutured together transversely, completing the pyloroplasty.

Parietal cell vagotomy (PCV): This operation requires more meticulous exposure of the esophageal hiatus than that needed for a truncal vagotomy. The hiatus is exposed as above, and the main vagal trunks supplying the stomach are identified, but not divided. The stomach is retracted downward, and it is often helpful to divide a portion of the gastrocolic omentum to facilitate grasping the stomach. Nerve branches supplying the body of the stomach (Fig. 7.2-2