INTRODUCTION — The term "total gastrectomy" implies the complete removal of all gastric tissue. Total gastrectomy is the treatment of choice for certain gastric tumors.
Perioperative considerations, surgical techniques for total gastrectomy and gastrointestinal reconstruction, and complications of total gastrectomy are reviewed here. Issues pertaining to partial gastrectomy are discussed elsewhere. (See "Partial gastrectomy and gastrointestinal reconstruction".)
The gastroesophageal junction refers to the point of transition from the abdominal esophagus to the proximal stomach. Carcinomas arising at or near the gastroesophageal junction pose unique challenges, both in their ability to arise from esophageal or gastric mucosa and in the complexity of jointly resecting the esophagus and stomach. Gastroesophageal junction tumors are reviewed elsewhere. (See "Multimodality approaches to potentially resectable esophagogastric junction and gastric cardia adenocarcinomas".)
SURGICAL ANATOMY AND PHYSIOLOGY OF THE STOMACH — The surgical anatomy of the stomach, including the anatomic divisions of the stomach (cardia, fundus, body, antrum, and pyloric sphincter (figure 1)), blood supply, and lymphatic drainage, is reviewed elsewhere (figure 2). (See "Partial gastrectomy and gastrointestinal reconstruction", section on 'Surgical anatomy and physiology of the stomach'.)
INDICATIONS — Total gastrectomy is indicated in the treatment of certain gastric tumors. These include:
●Gastric adenocarcinoma affecting the proximal stomach. (See "Surgical management of invasive gastric cancer", section on 'Proximal and esophagogastric junction tumors'.)
●Gastrointestinal stromal tumors (GISTs) affecting the proximal stomach, where a more limited resection is not technically feasible. (See "Local treatment for gastrointestinal stromal tumors, leiomyomas, and leiomyosarcomas of the gastrointestinal tract".)
●Type III gastric carcinoid affecting the proximal stomach. (See "Staging, treatment, and post-treatment surveillance of non-metastatic, well-differentiated gastrointestinal tract neuroendocrine (carcinoid) tumors", section on 'Stomach'.)
●Hereditary diffuse gastric cancer (CDH1 mutation), both in the prophylactic setting and when invasive gastric cancer has been confirmed. (See "Surgical management of hereditary diffuse gastric cancer".)
●Signet ring carcinoma, a diffuse form of gastric carcinoma, may benefit from total gastrectomy due to this tumor's diffuse submucosal spread and difficulty in obtaining clear margins with subtotal gastrectomy. (See "Clinical features, diagnosis, and staging of gastric cancer".)
●Benign indications for total gastrectomy are rare but include hemorrhagic gastritis that has failed medical and endoscopic management and intractable symptoms related to altered gastric physiology in patients who have undergone partial gastrectomy and reconstruction. (See "Management of stress ulcers", section on 'Subtotal or total gastrectomy' and "Postgastrectomy complications".)
Contraindications — Total gastrectomy should not be performed under the following circumstances:
●Patients with metastatic disease who are asymptomatic or minimally symptomatic should not undergo total gastrectomy, unless performed in the context of a clinical trial. The only published randomized controlled trial of chemotherapy versus surgery plus chemotherapy failed to show any benefit in adding surgery to the treatment plan [1]. Furthermore, the primary treatment of metastatic gastric cancer is chemotherapy, and total gastrectomy (which is associated with significant morbidities) can delay or prevent the patient from receiving treatment. Symptoms of obstruction are best managed by stenting, bypass, distal feeding tube, or palliative care. (See "Initial systemic therapy for locally advanced unresectable and metastatic esophageal and gastric cancer" and "Adjuvant and neoadjuvant treatment of gastric cancer".)
●Total gastrectomy should not be performed when a partial gastrectomy would provide negative margins due to the increased risk of complications associated with total gastrectomy compared with partial resection. The exception would be known or suspected hereditary diffuse gastric cancer, which mandates removal of the entire stomach because of the risk of a future malignancy in any gastric remnant. (See "Surgical management of hereditary diffuse gastric cancer".)
●Patients with significant medical comorbidities, particularly those with major cardiovascular and respiratory disease, may not be acceptable candidates for total gastrectomy, which is associated with significant morbidity and mortality. (See 'Perioperative morbidity and mortality' below.)
●Total gastrectomy may not be appropriate for patients who are malnourished, since, following total gastrectomy, the patient can be expected to lose weight. Some undernourished or malnourished patients may become better candidates for resection following a period of nutritional supplementation. (See "Overview of perioperative nutrition support", section on 'Preoperative nutrition support'.)
TUMOR STAGING — Prior to total gastrectomy, the patient should undergo preoperative staging to assess the extent of disease, including abdominal imaging, upper endoscopy, and staging laparoscopy.
Preoperative chest and abdominal computed tomography (CT) should be performed to rule out metastatic disease, which contraindicates gastrectomy [2]. Inconclusive results may need further focused imaging or staging laparoscopy to definitively confirm or rule out metastases. Positron emission tomography (PET) scanning is not routinely performed but may be used to evaluate equivocal findings on other imaging studies.
Endoscopy — Preoperative endoscopic evaluation should be used to assess the location of the tumor and its proximity to the gastroesophageal junction. The position of the gastroesophageal junction and the presence of hiatal hernia should also be noted. Total gastrectomy in patients with a shortened esophagus may require extension of the incision into the thorax.
For patients with hereditary diffuse gastric cancer, endoscopy should include a least 15 random biopsies of the antrum, incisura, fundus, and body if no gross mucosal abnormalities are noted [3]. Colonoscopy is performed preoperatively by many surgeons given a twofold increased risk of colorectal cancer in this population [4]. (See "Hereditary diffuse gastric cancer".)
Staging laparoscopy — In patients undergoing total gastrectomy for gastric adenocarcinoma, staging laparoscopy can be used to rule out metastatic disease, particularly carcinomatosis, which contraindicates the resection. (See 'Contraindications' above.)
The laparoscopy may be performed as a standalone procedure or just prior to the planned gastrectomy. As neoadjuvant chemotherapy becomes more commonly used in gastric cancer, we are increasingly performing this as a standalone procedure prior to the initiation of chemotherapy. This timing allows all involved to have information regarding the curability of the tumor prior to embarking on a treatment plan. (See "Surgical management of invasive gastric cancer", section on 'Staging laparoscopy'.)
Whether or not all patients with adenocarcinoma require staging laparoscopy prior to total gastrectomy, or just those with advanced disease, is controversial [5]. 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 "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 — Assessment of operative risk prior to gastric resection should identify the presence of other medical comorbidities, which may preclude resection. In general, patients undergoing total gastrectomy are older. A review of the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database from the years 1992 to 2002 revealed that 60 percent of patients undergoing surgery for gastric cancer were over the age of 75 years and approximately 70 percent had more than two associated comorbidities [6]. Since the majority of total gastric resections are performed under elective circumstances, 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".)
Antibiotics — Antibiotic prophylaxis is recommended for procedures that enter into the lumen of the gastrointestinal tract. (See "Antimicrobial prophylaxis for prevention of surgical site infection in adults" and "Antimicrobial prophylaxis for prevention of surgical site infection following gastrointestinal procedures in adults", section on 'Gastroduodenal procedures'.)
Appropriate antibiotic choices are given in the table (table 1). Patients should receive intravenous antibiotics prior to the incision, and dosing should be repeated intraoperatively for cases lasting more than three hours [7,8]. Randomized trials in patients undergoing gastrectomy (partial or total) have found no benefit for longer-duration postoperative antibiotics over perioperative (24 hour) dosing [9,10]. (See "Antimicrobial prophylaxis for prevention of surgical site infection in adults", section on 'Antibiotic administration'.)
Bowel preparation and decontamination — Although some surgeons routinely prepare the bowel prior to a total gastrectomy, we do not believe that such practice is necessary. Even if a part of the colon unexpectedly requires en bloc resection with a large gastric tumor, right colectomy can be done safely without mechanical bowel preparation.
However, there may be a role for oral enteral decontamination [11,12]. One trial that evaluated oral antibiotic decontamination prior to total gastrectomy randomly assigned 260 patients to placebo or oral decontamination with polymyxin B (100 mg), tobramycin (80 mg), vancomycin (125 mg), and amphotericin B (500 mg) four times per day orally from the day before the operation until postoperative day 7 [11]. On intention-to-treat analysis, significantly fewer esophagojejunostomy anastomotic leaks occurred in the oral decontamination group compared with the placebo group (2.9 versus 10.6 percent). The rate of pulmonary infection was also significantly lower among those who received oral decontamination (8.8 versus 22.3 percent). Mortality rates were not significantly different. Unfortunately, there was a high dropout rate during follow-up (55 of 260 patients). A subsequent smaller study did not find a significant difference [12]. Additional well-designed studies will be needed before routine oral decontamination can be recommended.
Thromboprophylaxis — Patients undergoing total gastrectomy for malignancy are at moderate-to-high risk for thromboembolism due to the nature and duration of the procedure, and pharmacologic prophylaxis is recommended (table 2). We also place intermittent pneumatic compression devices on all patients prior to induction of anesthesia and continue their use until the patient is ambulatory. (See "Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients".)
GENERAL CONSIDERATIONS — Total 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 [13]. (See "Epidural and combined spinal-epidural anesthesia: Techniques".)
Informed consent should include potential intraoperative and postoperative complications (eg, anastomotic leak), as well as the long-term effects of total gastrectomy, such as weight loss, vitamin deficiencies, and postgastrectomy syndromes. (See 'Perioperative morbidity and mortality' below.)
Open versus laparoscopic total gastrectomy — A total gastrectomy can be performed via an open or laparoscopic approach. Each approach is technically demanding and best performed by surgeons with advanced skills and training. Although various groups have reported satisfactory short- and long-term outcomes from laparoscopic total gastrectomy, it should be noted that these reports are almost exclusively from high-volume cancer hospitals with extensive laparoscopic experience [14-16]. One case series reported a higher perioperative mortality rate and an increased risk of anastomotic leak after laparoscopic total gastrectomy compared with open surgery [17].
Margins of resection — For cancer resection, frozen sections at the proximal and distal gastric margins should be obtained to be certain that the margins are free of carcinoma.
When performing prophylactic gastrectomy for hereditary diffuse gastric cancer, the distal resection should be carried at least one centimeter distal to the pylorus. Frozen sections should be obtained of the proximal margin to confirm that all gastric mucosa has been removed. If gastric mucosa at the proximal resection is identified, a more proximal resection to esophageal mucosa is needed. Extension of the incision into the left thorax may be needed to achieve an adequate proximal margin in patients with a shortened esophagus.
In the setting of gastrointestinal stromal tumors (GISTs), frozen section evaluation may not be necessary, since the gross margin is representative of the microscopic extent of the tumor.
Extent of nodal dissection — For patients with gastric cancer, lymphadenectomy is performed with the gastric resection. The lymph node stations (table 3) are grouped according to location (figure 3) and follow the extent of lymph node dissection (D1 through D4). (See "Surgical management of invasive gastric cancer", section on 'Extent of lymph node dissection' and "Partial gastrectomy and gastrointestinal reconstruction", section on 'Lymph node dissection'.)
In the rare instance of total gastrectomy for benign reasons, lymph node dissection is not required.
Gastric adenocarcinoma — A formal lymph node dissection is required for invasive carcinomas. The extent of lymph node dissection remains highly controversial. A D1 lymph node resection is the minimal accepted standard. Randomized trials have failed to find a survival benefit for more aggressive surgery, although it may be an acceptable offer in skilled hands [18-25]. A minimum of 15 lymph nodes should be harvested, regardless of type of lymph node dissection, to ensure accurate staging of the patient [18]. A detailed description of the definitions of the extent of lymph node dissections for gastric cancer is provided elsewhere. (See "Surgical management of invasive gastric cancer", section on 'Extent of lymph node dissection'.)
GIST tumor — No lymph node dissection is required for GIST tumors, as lymph node metastases are rare.
Type III gastric carcinoid — Due to the rarity of this tumor, there are no large studies available to examine outcomes related to the extent of lymph node dissection. But, since lymph node metastases are common with gastric carcinoid, a lymph node dissection should be performed. All visibly involved nodes should be included in the dissection when technically feasible. As with gastric carcinoma, a more extensive lymph node dissection provides better staging and may provide some survival advantage, but with a higher risk for complications.
Prophylactic gastrectomy — During prophylactic total gastrectomy for those with CDH1 mutation, only those lymph nodes that are harvested with the gastrectomy specimen are removed. A formal lymph node dissection is not needed. (See "Surgical management of hereditary diffuse gastric cancer".)
Vagus nerve preservation — During skeletonization of the distal esophagus, hepatic and celiac branches of the anterior and posterior vagal nerves, respectively, should be preserved. Bilateral truncal vagotomy results in gallstone formation or diarrhea in up to 30 percent of patients, which can be reduced to ≤5 percent if the celiac and hepatic branches can be preserved [26,27]. (See 'Total gastrectomy' below and "Postgastrectomy complications", section on 'Postvagotomy diarrhea'.)
PROCEDURE — Once the abdomen has been entered, total gastrectomy is performed by exposing and isolating the stomach, then dividing the esophagus and proximal duodenum and removing the specimen. Surgical margins are evaluated with frozen section, as indicated, and if clear, reconstruction is undertaken to restore gastrointestinal continuity. (See 'Margins of resection' above and 'Gastrointestinal reconstruction' below.)
Because a thoracotomy may be needed to obtain a clear proximal margin, the patient should be prepared and draped for that possibility. An upper abdominal midline incision from the xiphoid process of the sternum to the umbilicus is generally adequate. Alternatively, a bilateral subcostal (ie, chevron) incision may be used with similar exposure. (See "Incisions for open abdominal surgery".)
Once the abdomen is entered, the left triangular ligament of the liver should be taken down. A self-retaining retractor (eg, Thompson, Omni) can be used to retract the upper abdominal wall and left liver to provide better exposure of the gastroesophageal junction.
Total gastrectomy — To resect the stomach:
●Take the greater omentum off the transverse colon and mesocolon inferiorly to resect the omentum with the stomach en bloc when managing gastric carcinoma (figure 4). For prophylactic gastrectomy, the greater omentum can be preserved with the transverse mesocolon inferiorly (figure 5).
●Identify the pylorus (figure 6) and mark it with a suture (eg, 3-0 Prolene).
●Ligate the right gastric and right gastroepiploic vessels (figure 6).
●Transect the duodenum distal to the pylorus using a gastrointestinal anastomosis stapler (GIA) (figure 7). Care is taken to avoid injury to biliary and portal structures. Imbricate the staple line of the duodenal stump.
●Continue the dissection cephalad along the lesser curvature of the stomach by dividing and ligating the gastrohepatic ligament toward the diaphragm (figure 8).
●Identify and divide the left gastric vessels (figure 8). Dissect along the greater curvature of the stomach just outside the gastroepiploic arcade.
●Encircle the esophagus with a Penrose drain, and divide each crus of the diaphragm. Skeletonize the distal esophagus, but preserve the hepatic and celiac branches of the anterior and posterior vagus. Place four stay sutures (eg, 2-0 Prolene) circumferentially in the esophagus approximately 2 cm proximal to the presumed gastroesophageal junction. (See 'Vagus nerve preservation' above.)
●Transect the distal esophagus using a pursestring device (figure 9). Place the anvil of the EEA stapler into the distal esophagus, which will be used to create the esophagojejunal anastomosis, and tighten the pursestring suture. (See 'Gastrointestinal reconstruction' below.)
●As an alternative to the last two steps, the distal esophagus may be divided with a GIA stapler, and the anvil of the EEA stapler can be introduced across the GIA staple line via a specialized nasogastric tube introduced orally (eg, Orvil device). In this instance, stay sutures may be omitted. A hand-sewn anastomosis is technically possible but rarely done as it is technically more challenging, provides no advantage to the patient, and requires more time to perform.
Gastrointestinal reconstruction — The optimal method of reconstruction after total gastrectomy would provide for a functional reservoir, preserve duodenal and jejunal continuity, and minimize postgastrectomy functional disturbance [28-30]. No one reconstruction technique fulfills all these criteria; however, pouch reconstruction appears to have better functional outcomes and improved quality of life compared with other types of reconstruction [30-35]. We prefer to use a Hunt-Lawrence type pouch with a Roux-en-Y jejuno-jejunal anastomosis (figure 10).
Options for restoration of gastrointestinal continuity include a straight esophagojejunal anastomosis, looped esophagojejunal anastomosis (figure 11), jejunal interposition, colon interposition, and jejunal pouch construction, which can be brought behind the colon (Hunt) or in front of the colon (Rodino) [28].
A meta-analysis pooled the outcomes of 17 randomized trials and 8 observational studies involving 1621 participants and associated gastric pouch reconstruction with a significantly decreased incidence of esophagitis and heartburn (63 percent relative reduction [RR]), dumping syndrome (73 percent RR), and food intake disturbance (50 percent RR) at one to two years [30]. Albumin levels and body mass index were also higher among pouch patients in the same time frame. Pouch reconstruction increased operation time slightly (259 versus 236 minutes) but did not increase morbidity or mortality or length of hospital stay.
Small intestinal reconstruction techniques that preserve propulsion initiated by the duodenal pacemaker maintain antegrade flow of duodenal contents into the jejunum, thereby preventing retrograde and mixed propulsion [28,36-38]. This may be best accomplished using Roux-en-Y reconstruction. A trial of 60 patients found that patients who received duodenal continuity and pouch reconstruction after total gastrectomy had higher body weight and better physiologic regulation of gastrointestinal hormones than those who underwent other reconstructions that did not preserve passage of contents through the duodenum [39]. This study, however, did not report on perioperative complications associated with the different reconstruction techniques.
To construct a Hunt-Lawrence pouch with a Roux-en-Y (figure 10):
●Transect the jejunum distal to the ligament of Treitz. Bring the jejunal loop anterior to the colon up to the esophagus.
●Fold the jejunum back onto itself, placing traction sutures along the antimesenteric border of the jejunum to hold the limbs together. The optimal length of the pouch has not been well studied. One small trial found that 13 patients with a 9 cm pouch were better able to eat at their preoperative intake level and maintain body weight compared with 14 patients who had a 12 cm pouch [40]. We make the pouch approximately 10 cm.
●Make an incision in each loop caudally, and fire a GIA stapling device to create a side-to-side anastomosis.
●Use an EEA circular stapling device to create the anastomosis between the pouch and the esophagus. Introduce the long arm of the EEA stapler through the pouch, open the stapler to push the center post through the proximal pouch, using a scalpel or electrocautery to complete the opening. Place a pursestring suture around the pin and pull to snug the tissue around the post. Connect the posts of the long arm and anvil of the EEA device. Close the device, firmly apposing the esophageal and jejunal tissue, and fire. Gently pull the EEA anvil through the anastomosis and remove the device from the pouch.
●Close the caudal pouch opening transversely using a TA or GIA stapling device.
●Anastomose the proximal jejunum to the efferent limb of the pouch in an end-to-side fashion 20 cm distal to the caudal end of the pouch. We generally fashion a stapled anastomosis, but a hand-sewn technique can also be used; either option is equally effective.
●We do not place a nasojejunal tube through the anastomoses [41].
Feeding jejunostomy — A jejunal feeding tube may be placed approximately 20 cm distal to the Roux-en-Y jejuno-jejunostomy in patients with preoperative weight loss or other risk factors for complicated or delayed recovery. We create a Stamm type jejunostomy using a 14 French T-tube, secured with a double pursestring (3-0 absorbable suture) and anchored to the anterior abdominal wall (figure 12) [42].
The feeding tube provides enteral access for early enteral feeding, as well as delivery of enterally administered medications in the postoperative period, and can be used for prolonged access in those who develop complications. The routine use of jejunal feeding tubes, however, is controversial since there are conflicting data as to whether it increases or decreases the morbidity of the procedure [43-45]. (See 'Perioperative nutritional support' below.)
POSTOPERATIVE MANAGEMENT AND FOLLOW-UP
Perioperative nutritional support — Patients are initially maintained on intravenous fluids and are not given anything to eat by mouth (ie, nil per os [NPO]). If a jejunostomy tube is placed during the operation, then this allows for early postoperative enteral feeding while the patient is NPO. Tube feeding can be initiated two to three days postoperatively and advanced according to the patient's tolerance. The presence of a postoperative ileus may limit the tolerance to tube feeding, particularly in the first days after surgery. (See "Overview of perioperative nutrition support", section on 'Early enteral feeding'.)
Although practices vary, we obtain a Gastrografin swallowing study between postoperative days 3 and 5 to evaluate the esophago-jejunal anastomosis for leak prior to initiating an oral diet.
Diet — In the absence of anastomotic leak on Gastrografin swallow, we start a liquid diet and advance to a soft diet over 24 to 48 hours. 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 may contribute to dumping syndrome and may need to be avoided. (See "Postgastrectomy complications", section on 'Dumping syndrome'.)
Alteration in dietary intake and weight loss are to be anticipated with this procedure. Close involvement with a dietitian familiar with postgastrectomy patients is advisable to help patients adjust to their new dietary regiment and minimize weight loss. Vitamin and mineral supplementation are also required.
Endoscopy — Routine surveillance endoscopy is not necessary. Endoscopy is appropriate when symptoms warrant investigation. Locoregional recurrence of adenocarcinoma in the setting of total gastrectomy is almost universally fatal, and there is no evidence that early detection of recurrence prolongs life.
PERIOPERATIVE MORBIDITY AND MORTALITY — The risk of perioperative death from gastrectomy is associated with patient age and extent of lymph node dissection. Patient nutritional status may also be a factor. Major clinical trials have reported perioperative mortality rates ranging from 2 to 13 percent [20,46]. Death is due to hemorrhage, sepsis, cardiovascular and respiratory events, and thromboembolism [20].
Perioperative surgical complications following total gastrectomy are primarily due to the consequences of anastomotic leak [47,48]. Long-term surgical complications include late esophageal stricture and postgastrectomy syndromes.
Anastomotic complications — Disruption of the esophagojejunal anastomosis is the most worrisome complication in the early postoperative period. The jejuno-jejunal anastomosis is rarely a problem. Various groups have reported esophageal leak rates of 5 to 7 percent [41,49,50]. Minor leaks without systemic sepsis can be managed conservatively with antibiotics, intestinal decompression, and percutaneous drainage of any associated fluid collections or abscess. Intestinal decompression in the absence of the stomach is accomplished using a nasogastric tube placed into the jejunum distal to the esophageal anastomosis, typically using fluoroscopic guidance. A covered stent across the anastomosis may also be applied with good effect [51].
Major disruption that requires reoperation is fraught with difficulties and is associated with increased mortality. Overall, the mortality rate associated with disruption of the esophago-jejunal anastomosis is approximately 30 percent [50]. The occurrence of anastomotic leak increases the risk for subsequent anastomotic stricture.
Stricture of the esophagojejunostomy is reported in approximately 4 percent of patients [52]. Patients with anastomotic stricture will usually present with dysphagia. Upper endoscopy can diagnose the stricture, which can be also be dilated endoscopically usually with good results; however, repeated sessions may be needed.
Postgastrectomy syndromes — A 10 to 15 percent decrease in body weight and postgastrectomy syndromes are common sequelae of total gastrectomy [47,53]. The dumping syndrome and diarrhea are most severe in the initial postoperative period and generally improve within 12 months [54]. Postgastrectomy complications are discussed in detail in another topic. (See "Postgastrectomy complications".)
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
●The term "total gastrectomy" implies the complete removal of all gastric tissue. Total gastrectomy is the treatment of choice for certain malignancies of the proximal stomach, diffuse signet ring gastric adenocarcinoma, and hereditary diffuse gastric cancer (CDH1 mutation), both in the prophylactic setting and when invasive gastric cancer has been confirmed. Benign indications for total gastrectomy are rare but may include hemorrhagic gastritis, and intractable symptoms in patients who have undergone prior partial gastrectomy. Metastatic disease and severe medical comorbidities contraindicate total gastrectomy. (See 'Indications' above and 'Contraindications' above.)
●For all patients undergoing total gastrectomy, we recommend intravenous antibiotic prophylaxis (Grade 1B). Appropriate antibiotic choices are given in the table (table 1). Mechanical bowel preparation is not necessary, but oral antibiotic decontamination of the gastrointestinal tract prior to total gastrectomy may decrease the rate of esophageal leak. However, before routine oral decontamination can be recommended, additional well-designed studies are needed. (See 'Antibiotics' above and 'Bowel preparation and decontamination' above and "Antimicrobial prophylaxis for prevention of surgical site infection in adults" and "Antimicrobial prophylaxis for prevention of surgical site infection following gastrointestinal procedures in adults", section on 'Gastroduodenal procedures'.)
●Thromboprophylaxis should be administered according the patient's risk for thromboembolism (table 2). For patients undergoing total 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. (See "Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients".)
●Patients undergoing total gastrectomy for malignancy should undergo preoperative staging to rule out metastatic disease, including computed tomography (CT) of the abdomen, and upper endoscopy, which can be used to evaluate the extent of locoregional disease using ultrasound but also evaluates the anatomy of the esophagus and stomach, which may affect the type of reconstruction. Staging laparoscopy may be indicated for patients with gastric adenocarcinoma; however, whether or not all patients require staging laparoscopy prior to total gastrectomy, or just those with advanced disease, is controversial. There is no formal role for staging laparoscopy for other malignant tumors of the stomach. (See 'Tumor staging' above and "Surgical management of invasive gastric cancer", section on 'Staging evaluation'.)
●Total gastrectomy is accomplished usually via a midline laparotomy by exposing and isolating the stomach, dividing the esophagus and proximal duodenum, removing the specimen, and then restoring gastrointestinal continuity. (See 'Procedure' above.)
•For most patients undergoing total gastrectomy, we obtain intraoperative frozen sections of the proximal and/or distal margins. For adenocarcinoma, the margins should be clear of tumor. For patients undergoing prophylactic gastrectomy, the proximal margin should be clear of gastric mucosa. (See 'Margins of resection' above.)
•For patients undergoing total gastrectomy for gastric adenocarcinoma or carcinoid, we perform a D1 lymphadenectomy, rather than a lesser (D0) or greater amount (D2). A more extended lymphadenectomy increases perioperative morbidity and mortality of an already potentially morbid operation. For patients undergoing prophylactic gastrectomy for CDH1 mutation, gastrointestinal stromal tumors (GISTs), or the rare instance of total gastrectomy for benign reasons, lymphadenectomy is not needed. (See 'Extent of nodal dissection' above and "Surgical management of invasive gastric cancer", section on 'Extent of lymph node dissection'.)
•Whenever possible, the hepatic branch of the anterior vagus nerve and the celiac branch of the posterior vagus nerve should be preserved, rather than sacrificing these nerves with the specimen. Vagus nerve preservation minimizes the incidence of gallstone formation and diarrhea, which can occur in patients who undergo truncal vagotomy. (See 'Vagus nerve preservation' above.)
•We suggest a pouch reconstruction rather than a straight esophago-jejunal anastomosis (Grade 2B). Pouch reconstruction and maintenance of antegrade flow from the duodenum improve postoperative quality of life. We prefer the Hunt-Lawrence type pouch with a Roux-en-Y jejuno-jejunal anastomosis. (See 'Gastrointestinal reconstruction' above.)
●Postoperatively, the patient is maintained on intravenous fluids. Standard enteral feeding can be initiated on postoperative day 2 or 3, if a jejunostomy tube is in situ. We frequently obtain a Gastrografin swallow study between postoperative days 3 and 5, although the practice is variable and not mandatory. If no leak is present, a diet can be initiated. Consultation with a dietitian familiar with postgastrectomy patients should be obtained to help the patient adjust to their new dietary regimen. Vitamin and mineral supplementation will be required. (See 'Postoperative management and follow-up' above.)
●Perioperative mortality rates following total gastrectomy range between 2 and 17 percent, depending upon patient age and extent of lymph node dissection. Perioperative surgical complications following total gastrectomy are primarily due to the consequences of anastomotic leak, which occurs in 5 to 7 percent of patients. Long-term surgical complications include late esophageal stricture and postgastrectomy syndromes. (See 'Perioperative morbidity and mortality' above.)
ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Debrah Wirtzfeld, MD, MSc, FRCSC, FACS, who contributed to an earlier version of this topic review.
