INTRODUCTION — Partial gastric resection is used to treat cases of benign gastric disease for which resection is indicated; to treat malignant gastric tumors, such as adenocarcinoma, where sufficient margins can be achieved; to treat selected cases of gastrointestinal stromal tumor (GIST); and to manage complications related to conservative management of lymphomas. The first antrectomy for gastric cancer was performed by Ludwik Rydygier in 1880 [1]. The patient lived for 12 hours, passing away from postoperative shock. The first antrectomy in which the patient survived the operation was performed by Theodor Billroth in 1881 [1]. The patient subsequently passed away from metastatic disease. Antral resection was felt by many to be too severe for the treatment of benign disease, but partial gastrectomy became the treatment of choice for ulcer disease after a seminal paper was published in 1910 [1,2]. However, surgery is uncommonly needed in the era of modern antiulcer therapies, being reserved predominantly for complications or refractory disease.
The extent of gastric resection and type of reconstruction chosen impacts the nature of perioperative and later complications, particularly the development of postgastrectomy syndromes. In Japan and other countries where the incidence of early gastric cancer is common, function-preserving techniques, including pylorus-preserving segmental gastrectomy (PPSG) and vagus nerve preservation, have been promoted. The role of these techniques in treating patients in North America has not been well studied. A variety of options following partial gastrectomy are available to restore gastrointestinal continuity, the most common of which are the Billroth I, Billroth II, and Roux-en-Y reconstructions.
The indications and techniques for partial gastric resection and reconstruction, perioperative care, and complications will be reviewed here. The diagnosis and management of pathologies that may indicate the need for partial gastric resection are discussed in separate topic reviews. Total gastrectomy and reconstruction are discussed separately. (See "Total gastrectomy and gastrointestinal reconstruction".)
SURGICAL ANATOMY AND PHYSIOLOGY OF THE STOMACH — The stomach is located in the left upper quadrant of the abdomen. Anteriorly, the stomach is related to the left lateral lobe of the liver, diaphragm, colon, omentum, and anterior abdominal wall (figure 1). Posteriorly, the stomach is associated with the pancreas, spleen, left kidney and adrenal gland, splenic artery, and left diaphragm (figure 2 and figure 3).
The stomach is divided anatomically into five sections, with each section based upon histologic differences and with each having a unique role in the process of digestion (figure 4). These sections include [3] (see "Physiology of gastric acid secretion"):
●Cardia – The proximal portion of the stomach adjacent to the lower esophageal sphincter. It contains mucus neck cells and endocrine cells.
●Fundus – The portion of the stomach that rises above the level of the cardiac opening. It contains parietal cells, chief cells, endocrine cells, and mucus neck cells.
●Body – The portion of the stomach that lies between the fundus and the antrum. It contains cell types that are similar to the fundus.
●Antrum – The distal portion of the stomach demarcated from the body of the stomach on the lesser curvature by the angular incisura. It contains pyloric glands, endocrine cells, mucus neck cells, and G cells.
●Pyloric sphincter – A thick muscular valve separating the antrum from the duodenum. It contains mucus neck cells and endocrine cells.
The blood supply to the stomach is predominantly derived from the branches of the celiac artery (figure 1). The left gastric artery, which is derived from the celiac artery, courses along the lesser curvature of the stomach and anastomoses with the right gastric artery, which is a branch of the common hepatic artery. The right and left gastroepiploic arteries arise from the gastroduodenal artery and splenic arteries, respectively, and anastomose along the greater curvature. The short gastric arteries arise from the splenic artery and supply the fundus of the stomach. The gastric veins (left and right) parallel the arterial supply draining into the portal vein.
Lymphatic drainage — For patients with gastric cancer, lymphadenectomy is performed in concert with the gastric resection. The lymph node stations (table 1), as defined by the Japanese Gastric Cancer Association, are grouped according to location (figure 5) and follow the extent of potential lymph node dissection (D1 through D4) [4]. (See 'Lymph node dissection' below.)
●Perigastric lymph nodes – Refers to lymph nodes attached directly to the stomach along the greater and lesser curvatures
●Perivascular lymph nodes – Refers to lymph nodes along the gastric (left and right), gastroepiploic, hepatic (left and right), celiac, splenic, or mesenteric vessels
●Peripyloric – Refers to lymph nodes above and below the pylorus
●Peripancreatic – Refers to lymph nodes in the region of the pancreas
●Periaortic – Refers to lymph nodes in the vicinity of the aorta
TERMINOLOGY — The term "partial gastrectomy" is broad and encompasses essentially any procedure that does not remove the entire stomach. Partial gastrectomy can be proximal or distal. Distal gastrectomy can be performed to remove only the antrum, the distal two-thirds of the stomach, the distal four-fifths, or nearly the entire stomach as a subtotal gastrectomy. Other types of gastrectomy include wedge resection, mucosal/sleeve resection, and pylorus-preserving segmental gastrectomy. (See 'Resection techniques' below.)
Total gastrectomy refers to removal of the entire stomach including the gastroesophageal junction and pylorus. Total gastrectomy is discussed elsewhere. (See "Total gastrectomy and gastrointestinal reconstruction".)
INDICATIONS — Partial gastrectomy may be indicated in the treatment of various stomach diseases both malignant and benign or, rarely, in the management of devascularization injuries of the stomach due to trauma or other insults.
Malignant tumors — Whether partial gastrectomy is appropriate for the management of malignant tumors of the stomach depends upon the ability to control local disease by obtaining an appropriate margin [5]. In patients with malignant tumors, partial gastric resection and reconstruction may be indicated primarily, in combination with neoadjuvant therapy [6], to manage complications, or, in select circumstances, to treat tumor recurrence. The management of individual tumors for which partial gastrectomy may be indicated is discussed in detail elsewhere and includes:
●Adenocarcinoma. (See "Early gastric cancer: Treatment, natural history, and prognosis" and "Surgical management of invasive gastric cancer".)
●Gastrointestinal stromal tumors. (See "Local treatment for gastrointestinal stromal tumors, leiomyomas, and leiomyosarcomas of the gastrointestinal tract".)
●Neuroendocrine tumors. (See "Staging, treatment, and post-treatment surveillance of non-metastatic, well-differentiated gastrointestinal tract neuroendocrine (carcinoid) tumors" and "Multiple endocrine neoplasia type 1: Management" and "Management and prognosis of the Zollinger-Ellison syndrome (gastrinoma)".)
●Lymphoma – Surgery does not play a role in the primary treatment of most patients with gastric mucosa-associated lymphoid tissue (MALT) or non-MALT (diffuse large B cell) lymphomas, except to manage gastric perforation or bleeding not amenable to endoscopic management [7-9]. (See "Treatment of extranodal marginal zone lymphoma of mucosa associated lymphoid tissue (MALT lymphoma)".)
Benign tumors — Leiomyoma is the most common benign tumor for which partial gastric resection is performed [10]. Partial gastric resection has also been described in the diagnosis and/or treatment of less common submucosal lesions, including lipoma/adenomyoma and juvenile polyposis [11,12]. (See "Local treatment for gastrointestinal stromal tumors, leiomyomas, and leiomyosarcomas of the gastrointestinal tract".)
Ulcer disease — Antrectomy/distal gastrectomy may be required to manage ulcer disease but is a treatment of last resort only after conservative management, including eradication of Helicobacter pylori, has failed. Partial gastrectomy may also be indicated to manage complications of ulcer disease (eg, gastric outlet obstruction, bleeding, perforation) or if there is a suspicion of adenocarcinoma. (See "Surgical management of peptic ulcer disease".)
Antrectomy/distal gastrectomy may also be necessary to remove the source of hypergastrinemia in selected patients with Zollinger-Ellison syndrome or in those with type I (not associated with multiple endocrine neoplasia [MEN]) or type II (associated with MEN-1) gastric carcinoid, with the extent of resection determined by the size and number of lesions. Patients with type III gastric (sporadic) carcinoid may require antrectomy/distal gastrectomy or total gastrectomy with extended lymph node dissection. (See "Management and prognosis of the Zollinger-Ellison syndrome (gastrinoma)" and "Staging, treatment, and post-treatment surveillance of non-metastatic, well-differentiated gastrointestinal tract neuroendocrine (carcinoid) tumors".)
Bariatric or metabolic surgery — Partial gastric resection, in the form of sleeve gastrectomy, has been used in the management of obesity. The indications for bariatric or metabolic surgery, sleeve resection, and other bariatric surgical procedures are discussed elsewhere. (See "Bariatric surgery for management of obesity: Indications and preoperative preparation".)
Trauma — Partial gastric resection may be necessary to manage significant injuries to the stomach. Because the stomach is well vascularized, resection is typically limited to the removal of devitalized tissue. (See "Traumatic gastrointestinal injury in the adult patient".)
CONTRAINDICATIONS — Contraindications to abdominal surgery, in general, include systemic comorbidities that preclude safe administration of anesthesia. (See 'Medical risk assessment' below.)
Antrectomy for ulcer disease should not be performed if pyloric inflammation prevents safe dissection and preservation of surrounding structures (eg, portal triad, pancreas). Surgical bypass in the form of a gastroenterostomy may be a better option. Patients with recurrent, severe, and/or unusual disease (significant duodenal ulceration) should be screened for gastrinoma prior to surgical intervention [13].
Contraindications for patients with malignant disease — The ability to offer partial gastrectomy for malignant disease will depend upon the type of tumor, the extent of local disease and the ability to achieve appropriate surgical margins, and the presence of metastatic disease.
●Most surgeons would treat proximally placed malignant adenocarcinoma of the stomach with a total gastrectomy rather than a proximal subtotal gastrectomy. (See 'Optimal surgical margin' below and "Total gastrectomy and gastrointestinal reconstruction".)
●An important contraindication to partial gastrectomy is presumed or proven hereditary diffuse gastric cancer [14,15]. Total gastrectomy with intraoperative mucosal assessment to ensure negative proximal and distal margins is a more appropriate treatment for the majority of patients. (See "Hereditary diffuse gastric cancer" and "Total gastrectomy and gastrointestinal reconstruction".)
●For incurable advanced gastric cancer, chemotherapy is the standard of care. In a randomized trial, gastrectomy followed by chemotherapy did not show any survival benefit compared with chemotherapy alone [16]. Thus, gastrectomy cannot be justified in patients with metastatic adenocarcinoma of the stomach unless complications such as obstruction, bleeding, or perforation cannot be managed using other means. Obstruction can selectively be managed by gastroenteric bypass rather than resection in the setting of an advanced, locally aggressive tumor. Bleeding can be managed in select cases by external beam radiation rather than surgery. (See "Local palliation for advanced gastric cancer".)
●Many patients with advanced gastric adenocarcinoma may be candidates for neoadjuvant chemotherapy prior to consideration for gastric resection [17-20]. The British Medical Research Council Adjuvant Gastric Cancer Infusional Chemotherapy (MAGIC) trial evaluated a neoadjuvant regimen (ECF: epirubicin, cisplatin, fluorouracil) for T2 through T4 and/or node-positive gastric adenocarcinoma [20]. It found that ECF significantly improved five-year survival over surgery alone (35 versus 23 percent, hazard ratio 0.75, 95% CI 0.6-0.93). A German multi-institution trial has shown that the perioperative use of fluorouracil with leucovorin, oxaliplatin, and docetaxel (FLOT) is markedly superior to ECF and thus established a new standard for systemic therapy [21]. (See "Surgical management of invasive gastric cancer", section on 'Adjuvant and neoadjuvant therapy' and "Adjuvant and neoadjuvant treatment of gastric cancer".)
●Patients with metastatic gastrointestinal stromal tumors (GISTs) should be managed by a multidisciplinary team, including surgery and medical oncology. Resection should be reserved for patients with complications or those showing minimal response of the symptomatic primary tumor to targeted therapies such as imatinib. (See "Adjuvant and neoadjuvant therapy for gastrointestinal stromal tumors".)
TUMOR STAGING — Patients undergoing partial gastric resection for malignancy should undergo preoperative staging to the extent that is possible (table 2), including computed tomography (CT) of the abdomen, or endoscopic ultrasound, to evaluate the extent of locoregional disease and the presence of metastatic disease, which may contraindicate the resection. (See "Clinical features, diagnosis, and staging of gastric cancer" and "Surgical management of invasive gastric cancer", section on 'Staging evaluation'.)
Staging laparoscopy may be indicated for patients with gastric adenocarcinoma; however, the selection of patients who need staging laparoscopy is controversial. An expert international multidisciplinary panel felt that the usefulness of staging laparoscopy was indeterminate, although some evidence-based guidelines do encourage at least selective use of the procedure [22-24]. Whether staging laparoscopy should be a separate procedure or concurrent at the time of the planned resection has not been evaluated, although in our institution we are increasingly favoring performing laparoscopy prior to initiation of systemic treatment as FLOT (fluorouracil with leucovorin, oxaliplatin, and docetaxel) chemotherapy would not be recommended in the metastatic setting. There is no formal role for staging laparoscopy for other malignant tumors of the stomach. The indications for staging laparoscopy and general procedural details for performing staging laparoscopy for digestive malignancies are discussed elsewhere. (See "Surgical management of invasive gastric cancer", section on 'Staging laparoscopy' and "Clinical features, diagnosis, and staging of gastric cancer", section on 'Staging laparoscopy' and "Diagnostic staging laparoscopy: General principles for staging primary digestive malignancies".)
PREOPERATIVE PREPARATION
Medical risk assessment — The preoperative assessment prior to gastric resection should identify the presence of medical comorbidities. The majority of gastric resections are performed under elective circumstances for which there is adequate time for risk assessment and optimization of the patient's medical status. Preoperative medical assessment is discussed elsewhere. (See "Evaluation of cardiac risk prior to noncardiac surgery" and "Evaluation of perioperative pulmonary risk" and "Preoperative medical evaluation of the healthy adult patient".)
Data from the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database from 1992 to 2002 indicated that 60 percent of patients undergoing surgery for gastric cancer were over 75 years, and approximately 70 percent had more than two associated medical comorbidities [25].
Antibiotic prophylaxis — Antibiotic prophylaxis is recommended for procedures that enter into the lumen of the gastrointestinal tract. (See "Antimicrobial prophylaxis for prevention of surgical site infection following gastrointestinal procedures in adults", section on 'Gastroduodenal procedures' and "Antimicrobial prophylaxis for prevention of surgical site infection in adults", section on 'Antibiotic administration'.)
Appropriate antibiotic choices are given in the table (table 3). We use antibiotics directed against skin and colonic flora. Although there is no direct evidence to support this practice, the recognized risk of potential colon injury, or the need to resect the colon en bloc when managing gastric tumors, particularly advanced tumors, may justify antibiotic prophylaxis as with elective colon resection [26,27]. (See "Antimicrobial prophylaxis for prevention of surgical site infection following gastrointestinal procedures in adults".)
Thromboprophylaxis — Thromboprophylaxis should be administered according the patient's risk for thromboembolism (table 4). Patients undergoing partial gastrectomy for malignancy are at moderate-to-high risk for thromboembolism, and pharmacologic prophylaxis is recommended. For all patients, we use intermittent pneumatic compression, which should be placed prior to induction of anesthesia and continued until the patient is ambulatory. The indications and specific therapeutic choices for preventing thromboembolism in surgery patients are discussed in detail elsewhere. (See "Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients".)
Informed consent — In addition to the risks associated with surgery, in general, and the risks of anesthesia, patients should be made aware of the potential for acute perioperative (eg, anastomotic leak, duodenal stump leak) and long-term complications (eg, anastomotic stricture, marginal ulcer, bowel obstruction) related to the procedure [28]. In addition, patients should be counseled about postgastrectomy syndromes, which are due to alterations in gastric anatomy and physiology. (See "Postgastrectomy complications".)
Patients undergoing partial resection for peptic ulcer disease, although rare, should also be made aware of the need for lifetime surveillance of the gastric remnant for the development of cancer, which can occur roughly 15 years or more after partial gastrectomy [29].
GENERAL CONSIDERATIONS — Partial gastrectomy is performed under general anesthesia. For patients undergoing upper abdominal surgery, non-narcotic thoracic epidural anesthesia may simplify postoperative pain management and allow early postoperative mobilization, which may expedite the return of gastrointestinal function [30,31]. (See "Epidural and combined spinal-epidural anesthesia: Techniques".)
Open versus laparoscopic partial gastrectomy — The choice between an open surgical versus laparoscopic approach to partial gastric resection depends upon the indication for surgery, the experience of the operator, and the preferences of the surgeon and patient. As with most procedures performed laparoscopically, the operating surgeon should have sufficient experience with the open procedure and should be able to perform a comparable anatomic dissection and reconstruction using laparoscopic techniques, particularly when managing malignancies.
Laparoscopic partial gastrectomy has been described for many indications [10,32-40]. The available data suggest that, compared with open gastrectomy, laparoscopic gastrectomy takes significantly longer to perform, but with increasing operator experience, operating times have decreased [37,41]. In systematic reviews, laparoscopic surgery is associated with quicker return of gastrointestinal function, faster ambulation, shorter hospital stay, and comparable complication and tumor recurrence rates [35,38,42]. However, most individual studies have been small and are likely not adequately powered to detect differences in important clinical outcomes.
A laparoscopic approach may be most feasible for limited gastric resections that require minimal dissection, such as with wedge sleeve resection for benign indications [10,37]; however, the laparoscopic approach has also been used for resecting malignant gastric tumors [33-35,38]. A systematic review identified one randomized trial and six observational studies comparing open and laparoscopic surgery for resectable gastric cancer [38]. The results of these studies were combined to evaluate the outcomes of 178 patients undergoing laparoscopic gastrectomy and 278 undergoing open gastrectomy. Laparoscopic gastrectomy took significantly longer to perform compared with open gastrectomy (weighted mean difference [WMD] 44 minutes, 95% CI 20-69) but was associated with less blood loss (WMD 122 cc, 95% CI 208 to -37) and shorter hospital stay (WMD -6.2 days, 95% CI 9.4 to -2.8). There were no significant differences between the laparoscopic and open groups concerning the number of lymph nodes resected, or for cancer-related mortality (adjusted to five years).
Laparoscopic gastrectomy for cancer is discussed in detail elsewhere. (See "Laparoscopic gastrectomy for cancer".)
Incision and exposure — The patient should be positioned supine. For open gastrectomy, a midline abdominal approach is typically used. A self-retaining retractor helps to retract the liver and intestinal contents, facilitating exposure. (See "Incisions for open abdominal surgery", section on 'Midline incision'.)
For a laparoscopic approach, the abdominal cavity is accessed and insufflated, and multiple ports are placed under direct vision (figure 6). Placing the patient in reverse Trendelenburg position moves the intestinal contents away from the upper abdomen. General issues related to laparoscopic access are discussed in detail elsewhere. (See "Abdominal access techniques used in laparoscopic surgery".)
Prior to initiating the dissection (open or laparoscopic), the abdominal cavity, including the peritoneal surfaces, should be thoroughly explored to evaluate for any metastatic disease. The extent of locoregional disease should also be assessed.
Extent of resection
Optimal surgical margin — For patients undergoing potentially curative surgery for gastric malignancy, a tumor-free resection margin (R0) on pathologic examination is the goal of resection. The effect of margin status on prognosis is discussed in detail elsewhere. (See "Surgical management of invasive gastric cancer", section on 'Prognosis'.)
Because of a propensity for intramural spread, a margin of resection around the tumor is needed to ensure complete excision of gastric adenocarcinoma. The optimal margin of resection has not been well studied and remains debated. Generally accepted margins are >2 to 3 cm for early gastric cancer and >4 to 6 cm for advanced gastric cancer [43,44]. A review of 465 patients undergoing distal gastrectomy for gastric adenocarcinoma found improved overall survival time for a proximal margin of 3.5 to 5.0 cm compared with a margin ≤3.0 cm (48 versus 23 months) [45]. For stage I disease, overall survival was similar for a 3.1 to 5.0 cm proximal margin as a >5.0 cm margin. For stage II to III disease, overall survival was influenced by T stage and nodal involvement, rather than margin.
However, even when the measured margin during postoperative pathologic examination is less than these values, patient survival may not be impacted [46]; distant failures predominate even in patients with positive surgical margins. (See "Surgical management of invasive gastric cancer", section on 'Sites of disease recurrence'.)
To identify whether the intraoperative margin is adequate, intraoperative frozen sections of the proximal and distal margins should be obtained in all patients undergoing potentially curative surgery. Based upon the results of these frozen sections, a wider excision may be necessary. However, experts in this area recognize that it may be very difficult to obtain a negative margin even with successive frozen sections [47]. Nevertheless, re-excision of a positive margin does improve the prognosis of some patients with gastric cancer [48].
Margins for lymphoma and gastrointestinal stromal tumors (GISTs) need not be as extensive (1 to 2 cm), although there is no agreement on specific size of adequate margins. The use of intraoperative frozen section for these lesions is not well described.
Lymph node dissection — The Japanese classification defines the level of lymph node dissection (table 1) by the stations of lymph nodes removed (figure 5) [4]. We find it more practical to use a broader classification that defines the extent of lymph node dissection according to the relationship of the nodes to the segment of stomach to be removed, as follows [10]:
●D0 – Refers to an incomplete D1 lymph node dissection or no formal lymph node dissection.
●D1 – Removal of lymph node basins directly related to the segment of stomach removed.
●D2 – Removal of lymph node basins directly related to the segment of stomach removed AND lymph node basins along major named neurovascular arcades supplying that region of the stomach.
●D3 – Removal of lymph node basins directly related to the segment of stomach removed AND lymph node basins along major named neurovascular arcades supplying that region of the stomach AND para-aortic lymphadenectomy.
The extent of lymph node dissection needed during gastric resection for gastric adenocarcinoma is somewhat controversial. Treatment guidelines published by the National Comprehensive Cancer Network, CancerCare Ontario, and European Society of Surgical Oncology recommend that D2 lymph node dissection is preferred over a D1 dissection [23,24]. However, Japanese surgeons routinely perform extended lymphadenectomy (D2 or D3) [49]. However, in view of the higher reported rates of operative mortality in randomized trials when more extensive dissection is performed, this recommendation should be tempered by where and by whom the operation is being performed. The issues surrounding this controversy are discussed in detail elsewhere. (See "Surgical management of invasive gastric cancer", section on 'Extent of lymph node dissection'.)
Sentinel lymph node dissection may become useful for patients with early gastric cancer [50,51]. However, technical issues need to be resolved before sentinel lymph node dissection is accurate enough to be routinely applied; the false negative rate has been unexpectedly high [52]. A systematic review identified 26 observational studies using sentinel lymph node detection using various methods, including colored dye, radiocolloid, and dye plus radiocolloid [53]. The false negative rate was 13 percent with dye plus radioactive colloid, 18.5 percent with radiocolloid alone, and 35 percent with dye alone. Other issues, such as the optimal type of tracer, site of injection, manner of detection and harvesting, and learning curve, all need to be resolved [51].
For patients with GISTs, no effort is made to perform an extended lymph node dissection, because lymph node involvement is rare. For patients with neuroendocrine tumors, the extent of the lymph node dissection will depend on the type of gastric neuroendocrine tumor. (See "Staging, treatment, and post-treatment surveillance of non-metastatic, well-differentiated gastrointestinal tract neuroendocrine (carcinoid) tumors", section on 'Stomach'.)
RESECTION TECHNIQUES — The type and extent of gastric resection is determined by the location, nature, and extent of disease. Each technique has defined indications and specific, although sometimes overlapping, reconstructive options.
The options for partial gastric resection are listed. Each of these techniques is briefly reviewed below.
●Local excision/wedge resection
•Benign tumor excision
•Traumatic injury to the stomach
•Gastrointestinal stromal tumors (GISTs) amenable to wedge resection with appropriate 1 to 2 cm gross margins
●Sleeve (tube) gastrectomy
•Management of obesity (bariatric or metabolic surgery)
●Proximal subtotal gastrectomy
•Malignant tumor of the proximal (upper one-third) of the stomach
•Traumatic injury
●Antrectomy/distal gastrectomy/pylorus-preserving segmental gastrectomy
•Malignant tumor in the distal (lower two-thirds) of the stomach
•Refractory peptic ulcer disease or ulcer disease associated with neuroendocrine tumors
•Traumatic injury
Local excision/wedge resection — The goal of wedge resection is to obtain an appropriate margin without significant narrowing of the stomach. Care must be taken near the gastroesophageal junction or the pylorus to avoid this problem. To perform local excision/wedge resection, the area of interest is identified and a gastrointestinal stapler can be fired once across the stomach margin or twice to remove a triangular wedge of gastric tissue.
Sleeve gastrectomy — Sleeve gastrectomy is a type of partial gastrectomy in which the majority of the greater curvature of the stomach is removed using gastric staplers, creating a tubular stomach. It is used almost exclusively as a bariatric procedure. (See "Laparoscopic sleeve gastrectomy".)
Antrectomy/distal subtotal gastrectomy — Antrectomy is used to treat patients with refractory peptic ulcer disease, neuroendocrine tumors, or gastric adenocarcinoma. When performed for distal (lower two-thirds) gastric adenocarcinoma, antrectomy/distal gastrectomy includes resection of associated lymph node basins for adenocarcinoma.
To perform antrectomy/distal subtotal gastrectomy (figure 7):
●Identify the proximal resection margin. The incisura is generally recognized as the proximal extent of resection in an antrectomy. However, if needed, carry the proximal dissection superior to the confluence of the gastroepiploic vessels to obtain a sufficient margin.
●Mobilize the greater omentum (figure 3) from the transverse colon to remove it with the specimen for tumor resection. The extent of omentectomy is determined by the proximal extent of the gastric resection. The omentum can be left in situ in the case of antrectomy for benign disease.
●Identify the pylorus. Ligate and divide the right gastric and gastroepiploic vessels at the pylorus.
●Skeletonize and transect the duodenum just distal to the pylorus using a linear stapler. Care should be taken to avoid injury to the structures of the portal triad.
●Oversew the duodenal stump using a running, permanent suture (eg, 3-0 Prolene) on a noncutting needle.
●Carry the dissection cephalad along the greater and lesser curves of the stomach. For adenocarcinoma, the lesser omentum (gastrohepatic ligament) should be harvested with the specimen provided there is not a variant hepatic artery (figure 8) coursing through this region. For patients with benign disease, harvest the greater curve of the stomach just outside the gastroepiploic arcade.
●For a subtotal gastrectomy, the distal left gastroepiploic arcade and some of the short gastric vessels will need to be ligated.
●Transect at the proximal stomach margin using a linear gastrointestinal stapler.
●For patients requiring a D2 nodal dissection, send the named nodal basins along the vascular arcades of the stomach as separate, labeled specimens for pathologic examination.
Function-preserving partial gastrectomy — Function-preserving techniques for partial gastrectomy have been introduced by the Japanese as a means to limit or avoid syndromes that result from altered anatomy and/or physiology following traditional methods of gastric resection and reconstruction (ie, postgastrectomy syndromes) [54-57]. Function-preserving techniques include those that preserve the pylorus (pylorus-preserving segmental gastrectomy [PPSG]) [54-56], those that preserve the distal named branches of the vagus nerves [57], and operations that create a pouch or "neo-stomach."
Pylorus-preserving segmental gastrectomy — PPSG, which resects a portion of the stomach but leaves the pylorus intact (figure 9), was originally developed as a treatment approach for gastric ulcer surgery as a means to improve quality of life and avoid postgastrectomy syndromes. This technique has been championed for patients with early gastric cancer (EGC), which accounts for nearly 50 percent of patients presenting with gastric cancer in Japan [54-56]. Regardless of the status of lymph node metastasis, five-year survival rates of 93 to 98 percent have been reported [54]. A PPSG approach has not been described in the North American literature, likely because most patients in North America present with more advanced disease.
In comparison with Billroth I distal gastrectomy, patients undergoing PPSG have fewer subjective postprandial complaints and lower rates of symptomatic bile reflux and gallstone formation [55]. There may also be an improved ability to maintain weight and a decrease in symptoms of early dumping and reflux gastritis [56]. (See "Postgastrectomy complications".)
An important aspect of PPSG is the use of lymph node stations (figure 5) as the landmarks for the extent of resection, more so than the anatomic landmarks used for the resections described above. To perform PPSG:
●Following omentectomy, harvest the lymph nodes along the right gastroepiploic vessels.
●Divide the right gastroepiploic arcade distal to the infrapyloric artery and carry the dissection along the greater curve of the stomach.
●Harvest the left gastroepiploic vessels with the station 4sb lymph nodes.
●Harvest the lymph nodes of the lesser curve, and preserve the hepatic and pyloric branches of the vagus nerves and right gastric vessels.
●Remove the distal stomach with station 7, 8, 9, and 11p lymph nodes, preserving 3 cm of antrum and the pylorus.
●Harvest the left gastric vessels and transect the stomach proximally with a 2 cm margin.
●Perform an end-to-end anastomosis of the proximal to distal gastric remnants using a full-thickness single-layer suture (eg, Gambee suture (figure 10)).
Preservation of the vagus nerves — Traditional resection techniques for gastric adenocarcinoma have not emphasized preservation of the vagus nerves, but this practice is supported by those who treat patients with early gastric cancer and can be performed in conjunction with a D2 lymphadenectomy [54-57]. Preserving the hepatic branch of the anterior vagus nerve and celiac branch of the posterior vagus nerve decreases the incidence of postoperative diarrhea and postgastrectomy gallstone formation [57]. (See "Vagotomy".)
Proximal subtotal gastrectomy — Proximal subtotal gastrectomy (figure 11) may be an option for tumors in the proximal (upper third) of the stomach that do not invade the gastroesophageal junction. However, total gastrectomy (figure 12) is the more often favored procedure. (See "Surgical management of invasive gastric cancer" and "Total gastrectomy and gastrointestinal reconstruction".)
Tumors of the gastroesophageal junction are managed with esophagogastrectomy, which is discussed elsewhere. (See "Surgical management of resectable esophageal and esophagogastric junction cancers", section on 'Esophagogastric junction cancer resection'.)
GASTROINTESTINAL RECONSTRUCTION — Reconstructive procedures can be broadly thought of as those that preserve duodenal continuity, those that preserve jejunal continuity, those that preserve both, and those that incorporate some form of pouch reconstruction. Duodenal continuity is important for preventing loss of fat-soluble vitamins, while jejunal continuity is important for preventing retrograde flow of jejunal contents, which can occur because transection of the jejunum interrupts the electrical activity normally initiated by the duodenal pacemaker, thus impairing antegrade peristalsis [58].
Ideally, gastric reconstruction would avoid adverse consequences related to the loss of stomach tissue and function (ie, postgastrectomy syndromes), but each type of reconstruction is associated with, at a minimum, some degree of dumping (early or late) since the pylorus is typically removed (except for pylorus-preserving segmental gastrectomy). The characteristics and postgastrectomy syndromes associated with each of these reconstructions are given in the table (table 5). (See "Postgastrectomy complications".)
The most common gastric reconstructive procedures following partial (typically distal) gastrectomy in North America are the Billroth I, Billroth II, and Roux-en-Y reconstructions.
Billroth I — The Billroth I reconstruction (figure 13) preserves duodenal and jejunal continuity by anastomosing the remnant stomach to the duodenal stump in a primary end-to-end fashion. Billroth I reconstruction is the preferred method of reconstruction when the proximal gastric remnant and the duodenal stump can be approximated without tension, which is generally possible only after antrectomy.
The most common postgastrectomy syndrome (table 5) associated with Billroth I reconstruction is reflux of biliary contents retrograde into the stomach, causing alkaline gastritis. If the residual gastric remnant is small or nonfunctional, there will likely be some degree of dumping. (See "Postgastrectomy complications".)
Billroth II — The Billroth II reconstruction (figure 13) anastomoses the remnant stomach to the proximal jejunum in an end-to-side fashion. This reconstruction preserves jejunal but not duodenal continuity and is used when a Billroth I reconstruction is not possible, such as with more extended distal gastrectomy (ie, more than the antrum is resected). The Billroth II reconstruction has an afferent limb from the duodenum and an efferent limb extending distally. For a Billroth II reconstruction, the jejunal anastomosis can be performed in an antecolic or retrocolic, isoperistaltic, or antiperistaltic fashion (figure 14). Functional differences between these have not been documented [59].
Following Billroth II reconstruction, patients can expect to suffer from alkaline reflux gastritis and some dumping (table 5), but unlike Billroth I reconstruction, Billroth II also leads to some degree of malabsorption, particularly of fat-soluble vitamins, because of loss of duodenal continuity. (See "Postgastrectomy complications".)
Roux-en-Y gastrojejunostomy — Roux-en-Y reconstruction (figure 7) diverts the bilious drainage away from the gastric remnant. Although patients suffer from lesser degrees of reflux than seen in Billroth reconstruction (I or II), patients report dumping to a greater or lesser extent [60]. However, Roux-en-Y reconstruction may lead to gastric atony, and this, together with the adverse effect of jejunal transection, contributes to a syndrome of abdominal pain and vomiting known as the "Roux syndrome" or "Roux stasis syndrome." Patients with severe Roux stasis syndrome may require completion gastrectomy. (See "Postgastrectomy complications".)
Roux-en-Y gastrojejunostomy can be used in the same situations as a Billroth II, although it does not preserve duodenal or jejunal continuity. The Roux-en-Y gastrojejunostomy anastomoses the remnant stomach to an isoperistaltic roux limb of jejunum. The proximal jejunum is anastomosed to the distal Roux limb in an end-to-side fashion (figure 11). The optimal length of the afferent limb has received little attention. There is a balance between a limb that is too short, which increases the risk of bile (alkaline) reflux gastritis, and one that is too long, which may increase the risk of Roux stasis syndrome. In observational studies, the appropriate length to minimize reflux and reduce the risk of Roux stasis syndrome appears to be approximately 40 cm [60-62]. In one of these studies, the Roux limb was significantly longer in patients with symptoms consistent with Roux stasis compared with those without stasis (41 versus 36 cm) [62]. Roux stasis was more common in women than men but equally common in patients with and without vagotomy.
Choice of reconstruction — The choice of reconstruction following antrectomy for ulcer disease or distal gastrectomy for tumor depends upon the remnant anatomy available for reconstruction, taking into consideration the complications related to the specific postgastrectomy physiology that will result. However, based upon randomized trials, Roux-en-Y reconstruction appears to be tolerated better overall and leads to a better quality of life compared with Billroth reconstruction (Billroth I or Billroth II). Whether to preferentially perform a Roux-en-Y in patients whose anatomy supports a Billroth I or Billroth II, or convert to a Roux-en-Y only if complications occur, remains controversial. For patients who have not undergone vagotomy, we suggest a primary Roux-en-Y reconstruction. Patients who have had a vagotomy have an increased risk of Roux stasis syndrome. (See 'Roux-en-Y gastrojejunostomy' above.)
A meta-analysis of 15 randomized trials comparing at least two of the gastric reconstruction techniques (ie, Billroth I, Billroth II, or Roux-en-Y reconstruction) following gastrectomy assessed postoperative morbidity and mortality, quality of life, and the incidence of postgastrectomy syndromes [63]. Although complication rates were similar, patients with a Roux reconstruction had fewer complaints of reflux gastritis and better quality of life. A later trial also confirmed this finding [64].
A Cochrane review of eight randomized trials comparing Billroth I with Roux-en-Y reconstruction after distal gastrectomy for cancer found a lower incidence of bile reflux with Roux-en-Y but lower morbidity and shorter hospital stay with Billroth I reconstruction. However, the overall quality-of-life scores did not differ between the two techniques [65]. All of the studies included in this review were from Asian countries. The applicability of these data to Western patients may be limited. Billroth I surgeries are limited to small, early, and quite distal lesions, which would be rare entities in the North American and European patient populations. Furthermore, Billroth I surgeries were done commonly in the ulcer surgery era but are rarely needed for benign gastric surgery currently. Thus, fewer Western surgeons may have real case experience with this procedure.
The longest follow-up comparing techniques was reported for a trial that followed 75 patients treated for duodenal ulcer for 12 to 21 years [66]. Patients were randomly assigned to Billroth II (n = 39) or Roux-en-Y (n = 36) reconstruction between 1984 and 1993. Patients who received a Roux-en-Y reconstruction had overall better clinical outcomes with a significantly lower incidence of reflux esophagitis (3 versus 33 percent), fewer abnormal findings on upper endoscopy of the distal esophagus and esophagogastric junction (10 versus 82 percent), and a lower incidence of Barrett's esophagus (3 versus 21 percent). The gastric remnant was also normal in significantly more Roux-en-Y patients (100 versus 18 percent). There were no differences between the groups in the incidence of H. pylori infection. It is interesting to note that the Roux limb in these patients was arbitrarily chosen to be 60 cm. Although the authors were concerned about the potential for the "Roux syndrome," it was not clinically apparent in their series.
In a retrospective comparative study of 1300 distal gastrectomies performed for cancer, Billroth I reconstruction was associated with the least amount of weight and nutritional loss at one-year follow-up [67]. Compared with Billroth I, Billroth II was associated with decreased body mass index and low protein and albumin, whereas Roux-en-Y was associated with decreased body mass index and low cholesterol. Other factors varied between the groups in this study, including use of open versus laparoscopic approach, extent of lymph node dissection, and final tumor stage. Thus, the results may not purely be a reflection of surgical choice but a composite of tumor, surgical, and patient factors.
POSTOPERATIVE CARE AND FOLLOW-UP — Enhanced recovery after surgery (ERAS), also known as fast-track protocols, has been used for selected patients undergoing gastric surgery [68,69]. Patients with American Society of Anesthesiology (ASA) grade >2 malnutrition are not candidates. The elements of a fast-track protocol are reviewed elsewhere. (See "Enhanced recovery after colorectal surgery".)
For most patients, the nasogastric tube can be discontinued in the recovery room or on the first day postoperatively. If a nasogastric tube becomes dislodged or has fallen out, it should not be replaced unless that patient has symptoms. The practice of routine nasogastric decompression is not recommended, in general, and the available data suggest that gastrointestinal decompression may not be needed even for patients undergoing esophageal or gastric surgery. (See "Inpatient placement and management of nasogastric and nasoenteric tubes in adults", section on 'Indications'.)
A systematic review identified five randomized trials comparing routine nasogastric or nasojejunal decompression (n = 361) to no decompression (n = 361) in patients undergoing gastrectomy for cancer [70]. A meta-analysis of three of these trials (two partial gastrectomy, one total gastrectomy) found that patients with no gastric decompression had a significantly shorter time to oral diet (weighted mean difference [WMD] 0.43 days, 95% CI 0.23-0.62). Time to flatus, anastomotic leakage, pulmonary complications, length of hospital stay, and morbidity and mortality were similar in both groups. A later review that included seven trials also found a significantly shorter time to oral diet (WMD 0.43 days, 95% CI 0.25-0.61) and a trend toward a decreased risk for pulmonary complications (relative risk 1.30, 95% CI 1.00-1.68). Rates for anastomotic leakage, morbidity, and mortality were similar between the two groups [71]. Subsequent studies appear to support these results [72-75].
Some patients may have prolonged spasm or edema of the gastrojejunal or jejunojejunal anastomoses leading to nausea and emesis. If the gastrointestinal decompression has been discontinued, a nasogastric tube may need to be replaced.
When nasogastric replacement is needed following proximal subtotal gastrectomy, we prefer placement under fluoroscopy to avoid any risk of disrupting the proximal anastomosis; for distal gastrectomy, fluoroscopic imaging may not be necessary.
Perioperative nutritional support — Prior to gastric resection, patients can have poor oral intake due to nausea, vomiting, or early satiety and may be malnourished, increasing the risk for surgical complications. In addition, some patients may not be able to resume oral intake due to spasm or edema of the gastrojejunal or jejunojejunal anastomoses [28]. In the setting of preoperative malnutrition, perioperative nutritional support should be provided, which can be initiated via total parenteral nutrition (TPN) or a feeding jejunostomy placed at the time of the gastric resection [76].
If a feeding jejunostomy tube is to be used, it should be placed into the jejunum approximately 30 to 40 cm beyond the most distal anastomosis. The tube should be flushed twice daily for the first 24 hours, and thereafter, it can be used to provide enteral support. Enteral feedings can be initiated as a dilute solution at approximately 10 mL per hour and increased to the target rate.
There may be a role for preoperative nutritional support if the patient's nutritional indices are severely depressed. (See "Overview of perioperative nutrition support", section on 'Preoperative nutrition support'.)
Postgastrectomy diet — The extent of alteration of oral intake will be determined by the size of the gastric remnant and the need to conservatively manage postgastrectomy syndromes. Small frequent meals, high in protein and inclusive of fat, should be consumed approximately six times per day. Liquids may need to be taken separately from solids. Meals high in simple carbohydrates can contribute to dumping syndrome and may need to be avoided. The patient should be followed closely, at least initially, by a dietician experienced with managing patients who have undergone this procedure.
Vitamin and mineral supplementation may also be necessary:
●Patients who have undergone subtotal gastrectomy will need vitamin B12 supplementation. (See "Clinical manifestations and diagnosis of vitamin B12 and folate deficiency".)
●Patients who have undergone reconstructive procedures that bypass the duodenum (eg, Billroth II, Roux-en-Y) may require supplementation of fat-soluble vitamins. (See "Overview of vitamin A" and "Overview of vitamin D" and "Overview of vitamin E" and "Overview of vitamin K".)
●Calcium and iron should also be supplemented. (See "Treatment of iron deficiency anemia in adults" and "Treatment of hypocalcemia".)
Follow-up — Following partial gastric resection, the patient should follow up to evaluate the incision(s) and overall recovery and periodically thereafter to monitor weight, nutritional status, and the presence of any symptoms that may indicate the development of complications related to the gastric resection or reconstruction. Symptoms may include weight loss, fever, abdominal pain, early satiety, persistent vomiting, reflux symptoms, hematemesis, and/or unexplained anemia. Further abdominal imaging or endoscopic evaluation may be needed. (See "Postgastrectomy complications" and "Endoscopic retrograde cholangiopancreatography (ERCP) after Billroth II reconstruction" and "ERCP in patients with Roux-en-Y anatomy".)
Following gastric resection for malignancy, scheduled follow-up is suggested to detect clinical symptoms of recurrence, which occurs most commonly in the first two to three years. However, it is important to note that most patients undergoing partial gastrectomy for adenocarcinoma do not fail surgical treatment due to gastric mucosal recurrence but rather develop nodal disease or distant metastases. These issues are discussed in detail elsewhere. (See "Surgical management of invasive gastric cancer", section on 'Post-treatment surveillance'.)
POSTGASTRECTOMY COMPLICATIONS — Complications following partial gastrectomy can be anatomic, related to the extent of gastric resection and the type of reconstruction, or physiologic, related to the loss of function in the section of stomach removed (table 5). Postgastrectomy complications are discussed in detail separately. (See "Postgastrectomy complications".)
PERIOPERATIVE MORTALITY — Perioperative mortality following partial gastric resection is low, even among appropriately selected candidates with malignant tumor. In series comparing open with laparoscopic gastric resection, no significant differences have been found, and reported perioperative mortality rates range from 1 percent to greater than 10 percent for patients of advanced age and with medical comorbidities [10,32-39,77,78].
Well-designed studies evaluating longer-term outcomes have traditionally been difficult as partial gastrectomy for benign disease has declined substantially over the last several decades [79,80]. The long-term evaluation of patients undergoing resection for adenocarcinoma is confounded by recurrent disease and overall high case fatality rate [46]. Disease-specific outcomes are discussed separately. (See "Early gastric cancer: Treatment, natural history, and prognosis".)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Gastric surgery for cancer".)
SUMMARY AND RECOMMENDATIONS
●Indications – The terms "partial gastrectomy" or "subtotal gastrectomy" are broad and encompass essentially any procedure that does not remove the entire stomach. Partial gastrectomy can be proximal or distal. Other types of gastrectomy include wedge resection, mucosal/sleeve resection, and pylorus-preserving segmental gastrectomy. Partial gastric resection is used to treat most cases of benign gastric disease for which resection is indicated (eg, ulcer disease, benign tumor, traumatic injury); malignant gastric tumors, such as adenocarcinoma, where sufficient margins can be achieved; and in selected cases of gastrointestinal stromal tumor (GIST), some neuroendocrine tumors, and complications related to treatment of lymphoma. (See 'Indications' above.)
●Contraindications – Partial gastrectomy may not be an appropriate choice if excessive inflammation, particularly in the region of the pylorus, precludes safe dissection (benign or malignant disease) or if the location or type of tumor indicates total gastrectomy or the need for primary medical therapy. An important contraindication to partial gastrectomy is presumed or proven hereditary diffuse gastric cancer; these patients should undergo total gastrectomy. For patients with gastric adenocarcinoma, partial gastric resection is contraindicated in the setting of metastatic disease when the patient is asymptomatic or if the extent of local disease prevents adequate surgical resection margins. In the latter case, total gastrectomy should be performed.(See 'Contraindications for patients with malignant disease' above.)
●Preoperative preparations
•Diagnostic evaluations – Patients undergoing partial gastric resection for malignancy should undergo preoperative staging, including CT of the abdomen, or endoscopic ultrasound to evaluate the extent of locoregional disease and the presence of metastatic disease, which may contraindicate the resection. Staging laparoscopy may be indicated for some patients with gastric adenocarcinoma, particularly if the tumor has adverse features. There is no formal role for staging laparoscopy for other malignant tumors of the stomach. (See 'Tumor staging' above.)
•Antibiotic prophylaxis – For all patients undergoing partial gastrectomy, antibiotic prophylaxis is recommended. For patients undergoing partial gastric resection who may require en bloc resection of the colon or are at risk for colon injury during resection, we suggest antibiotic prophylaxis appropriate to colon surgery (table 3), rather than another regimen (Grade 2C). (See 'Antibiotic prophylaxis' above and "Antimicrobial prophylaxis for prevention of surgical site infection following gastrointestinal procedures in adults" and "Antimicrobial prophylaxis for prevention of surgical site infection in adults".)
•Venous thromboembolic prophylaxis – Thromboprophylaxis should be administered according to the patient's risk for thromboembolism (table 4). For patients undergoing partial gastrectomy for malignancy, we recommend pharmacologic prophylaxis over no prophylaxis (Grade 1B). These patients are at moderate-to-high risk for thromboembolism. For all patients, we suggest intermittent pneumatic compression (IPC), rather than no compression (Grade 2C). IPC devices should be placed prior to induction of anesthesia and continued until the patient is ambulatory.
●Surgical techniques – The extent of gastric resection and type of reconstruction chosen is determined by the location, nature, and extent of disease and impacts the nature of perioperative and later complications, particularly the development of postgastrectomy syndromes. Partial gastrectomy procedures include wedge resection, antrectomy/distal gastrectomy, distal subtotal gastrectomy, proximal subtotal gastrectomy, pylorus-preserving segmental gastrectomy, and mucosal/sleeve resection. (See 'Resection techniques' above.)
•Margins – For patients undergoing partial gastrectomy for adenocarcinoma, we suggest a margin of 2 to 3 cm for early gastric cancer and 4 to 6 cm for advanced gastric cancer, rather than a lesser amount (Grade 2C). For patients with adenocarcinoma undergoing potentially curative surgery, we suggest intraoperative frozen sections of the proximal and distal margins. Based upon the results of the frozen sections, a wider excision may be necessary. Re-excision of a positive margin may improve the prognosis of some patients with gastric cancer. (See 'Optimal surgical margin' above and "Surgical management of invasive gastric cancer", section on 'Surgical treatment for localized disease' and "Surgical management of invasive gastric cancer", section on 'Sites of disease recurrence'.)
•Reconstruction – Several reconstructions are used to restore gastrointestinal continuity following partial gastrectomy. The most common are the Billroth I, Billroth II, and Roux-en-Y reconstructions with the choice between these depending upon the remnant anatomy available for reconstruction and the status of the vagus nerves. For patients who have not undergone vagotomy, we suggest Roux-en-Y reconstruction over Billroth reconstruction (Billroth I or Billroth II) (Grade 2B). (See 'Gastrointestinal reconstruction' above.)
•Function-preserving alternatives – Function-preserving techniques for partial gastrectomy have been introduced by the Japanese as a means to limit or avoid postgastrectomy syndromes. Function-preserving operations may preserve the pylorus, which minimizes the risk of dumping syndrome; preserve the vagus nerves, thereby improving gastrointestinal motility; or create a pouch or "neo-stomach," which improves gastric capacity. (See 'Function-preserving partial gastrectomy' above.)
•Open versus laparoscopic surgery – The choice between an open surgical versus laparoscopic approach to partial gastric resection depends upon the indication, experience of the operator, and preferences of the surgeon and patient. Perioperative outcomes may be improved with a laparoscopic approach; however, long-term outcomes, particularly oncologic outcomes, have yet to be determined. (See 'Open versus laparoscopic partial gastrectomy' above.)
●Postoperative care – Following partial gastric resection, the patient should follow up to evaluate the incision(s) and overall recovery and periodically thereafter to monitor weight, nutritional status, and the presence of any symptoms that may indicate the development of complications. Further abdominal imaging or endoscopic evaluation may be needed. Following partial gastrectomy for malignancy, scheduled follow-up is suggested to evaluate for recurrence. (See 'Follow-up' above and "Surgical management of invasive gastric cancer", section on 'Post-treatment surveillance'.)
●Outcomes – Complications following partial gastrectomy can be related to anatomic or physiologic alterations. The most concerning postoperative complication is anastomotic leak. The nature and severity of postgastrectomy syndromes depend upon the extent of gastric resection and the type of gastric reconstruction (table 5). (See 'Postgastrectomy complications' above and "Postgastrectomy complications".)
ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Debrah Wirtzfeld, MD, MSc, FRCSC, FACS, who contributed to an earlier version of this topic review.
