This document provides information on principles of gastrectomy, including: - A brief history of gastrectomy procedures from the early 19th century to modern developments. - Details on the anatomy, blood supply, lymph drainage of the stomach as relevant to gastrectomy. - Descriptions of different types and techniques of gastrectomy for treating conditions like cancer, ulcers, and obesity. - Information on pre-operative preparation, surgical techniques for different procedures like Billroth I and II reconstructions, and post-operative care and complications.

1. PRINCIPLES OF GASTRECTOMY

2. HISTORICAL PERSPECTIVE
• In 1602 Florian Mathies - first successful gastrotomy for a swallowed knife
• In 1793 Mathew Baille - first accurate description of gastric ulcers and cancers
• Early 19th century, Benjamin Travers reported on duodenal perforations.
• In 1810 Karl Theodor Merrem, - first successful pylorectomy on a dog.

3. HISTORICAL
PERSPECTIVE
• Prof. Theodore Billroth
• First Partial Gastrectomy (Billroth I) in 1882
• Woeffler –
• First Gastrojejunostomy
• First anastomosis-en-y to overcome the short comings of Gastro-
jejunostomy
• Cesar Roux of Lausanne
• popularized the anastomosis-en-y
• Prof. Theodore Billroth developed the (Billroth II)
• Partial gastrectomy intraop for an unresectable pyloric tumor

4. ANATOMY OF THE STOMACH

5. ARTERIAL SUPPLY TO THE STOMACH

6. VENOUS DRAINAGE OF THE STOMACH

7. LYMPHATIC DRAINAGE OF THE
STOMACH

8. N1 – (Peri-gastric Nodes)
3 cm of primary tumour
• No. 1 Right paracardial LN
• No. 2 Left paracardial LN
• No. 3 LN along the lesser curvature
• No. 4 LN along the greater curvature
• No. 5 Suprapyloric LN
• No. 6 Infrapyloric LN

9. N2 – Nodes on the Celiac trunk and its branches
• No. 8 common hepatic artery nodes
• No. 9 celiac artery nodes
• No. 10 splenic hilum nodes
• No. 11 splenic artery nodes

10. N3 – Para-aortic, paracolic
• No. 12a - Hepatoduodenal ligament
• No. 13 Posterior pancreatic head
• No. 14 Along the superior mesenteric vein
• No. 15 Along the middle colic vessels
• No. 16 Aortic hiatus
• No. 17 Anterior pancreatic head
• No. 18 Inferior margin of the pancreas
• No. 19 Infradiaphragmatic
• No. 20 Oesophageal hiatus of the diaphragm
• No. 110 Paraoesophageal
• No. 111 Supradiaphragmatic LN
• No. 112 Posterior mediastinal LN

11. GASTRIC SURGRIES IN GASTRIC CANCER
TREATMENT
• EXTENT OF LYMPHADENECTOMY
• D0 – Incomplete D1 dissection
• D1 – Group 1 (Peri-gastric) lymph nodes– (Stations 1 to 6)
• D2 – Group 1 & II (Stations 7 to 1I)
• D3 – Group I, II & III (Stations 12 to 14)
• D4 – Group I, II, III and paraaortic and paracolic nodes (station 15 and 16)

12. GASTRIC SURGRIES IN GASTRIC CANCER
TREATMENT
• RESECTION MARGINS
• R0 – Complete gross and microscopic resection
• R1 – Complete gross resection but positive microscopic margin
• R2 – Incomplete gross and microscopic resection
• Margin of at least 3 cm is for T2 or deeper tumors with an expansive growth pattern (types 1 and 2)
• Margins of at least 5 cm for those with an infiltrative growth pattern (types 3 and 4).
• When these rule cannot be met then examine the proximal resection margin by frozen section.

13. GASTRIC SURGRIES IN GASTRIC CANCER
TREATMENT
1. Curative Surgery
a. Standard Gastrectomy
• Principal surgical procedure performed with curative intent.
• It involves resection of at least two-thirds of the stomach with a D2 lymph node
dissection.
b. Non-standard gastrectomy
• The extent of gastric resection and/or lymphadenectomy is altered according to
tumor stages.

14. GASTRIC SURGRIES IN GASTRIC CANCER
TREATMENT
1. Curative Surgery
c. Modified surgery
• Extent of gastric resection and/or lymphadenectomy is reduced (D1, D1+, etc.)
compared to standard surgery.
d. Extended surgery
• Gastrectomy with combined resection of adjacent involved organs and/or
• Gastrectomy with extended lymphadenectomy exceeding D2

15. GASTRIC SURGRIES IN GASTRIC CANCER
TREATMENT
2. Non-curative Surgery
a. Palliative Surgery
• Surgery to relieve symptoms e.g., obstruction, bleeding
• Palliative gastrectomy or gastrojejunostomy
• Options depend on the resectability of the primary tumor and/or surgical risk
b. Reduction surgery
• Aims to prolong survival or to delay the onset of symptoms by reducing tumor volume

16. TYPES AND DEFINITIONS OF GASTRIC
SURGERY
• Types of Gastrectomies based on volume of stomach resected
• Total - All the stomach is removed including the cardia and pylorus
• Near Total - >90% of stomach is resected
• Subtotal – 80 to 90%
• Partial – 65 to 75%
• Hemigastrectomy – 50%
• Distal Gastrectomy – 35 to 50%

17. TYPES AND DEFINITIONS OF GASTRIC
SURGERY
• Total gastrectomy -- Total resection of the stomach.
• Distal gastrectomy – resection of distal 2/3 of the stomach including the pylorus
• Pylorus-preserving gastrectomy (PPG)
• Preserving the upper 1/3 of the stomach and the pylorus along with a portion of
the antrum.
• Proximal gastrectomy - resection includes the cardi whiles preserving the pylorus

18. TYPES AND DEFINITIONS OF GASTRIC
SURGERY
• Anatomical Extent of Gastric Resection
• Segmental gastrectomy –
• Circumferential resection of the stomach preserving the cardia and pylorus.
• Local resection.
• Non-resectional surgery -- (bypass surgery, gastrostomy, jejunostomy).

19. Types of Reconstruction after
Gastrectomy
• Total Gastrectomy
• Roux-en-Y esophagojejunostomy.
• Jejunal interposition.
• Colonic interposition
• Distal gastrectomy
• Billroth I gastroduodenostomy.
• Billroth II gastrojejunostomy.
• Roux-en-Y gastrojejunostomy.
• Jejunal interposition.
• Pylorus-preserving gastrectomy
• Gastro-gastrostomy.
• Proximal gastrectomy
• Esophagogastrostomy.
• Jejunal interposition.
• Double tract method.

20. GENERAL INDICATIONS OF GASTRECTOMIES
1.Complication of Peptic Ulcer Disease
• Intractable/Non-healing PUD
• Recurrent bleeding
• Large duodenal ulcer perforations -- > 1cm
2.Neoplastic lesions (benign or malignant) – for
curative or palliative measures
• Adenocarcinoma of the stomach
• Primary gastric melanoma
• Gastrointestinal stromal tumors (GISTs)

21. INDICATIONS OF GASTRECTOMIES
3.Nutritional therapy
• Obesity – Sleeve gastrectomy
4.Corrosive stricture of the stomach
5.Trauma

22. INDICATIONS FOR TOTAL GASTRECTOMY
• Total Gastrectomy
• Extent or location of tumor does not permit adequate resection of the tumor
• Tumors located in body, cardia or fundus of the stomach
• Diffuse type of tumor -- linitis plastica
Subtotal Gastrectomy
• Tumors limited to the antropyloric region
• Benign ulcers
• Nutritional therapy

23. PRE-OPERATIVE PREPARATION
• History taking
• Physical examination
• Diagnostic Investigations
• Upper GI Endoscopy with Biopsy -- to confirm or rule out neoplasm
• Abdominal CT Scan -- Involvement of adjacent structures
• Laparoscopy -- Tumor spread, fixity of tumour
• Supportive Investigations
• FBC, GXM, BUE and Cr, LFT, Chest Xray, ECG, ECHO

24. PRE-OPERATIVE PREPARATION
• Optimize the patient
1. Correction of anaemia
2. Correction fluid and electrolyte imbalances
3. Correction of hypoalbuminaemia
• Bowel preparation
• Gastric lavage starting at least 5 days before surgery
• Repeat 1 to 2 hrs. before surgery
• Effluent must be clear before surgery
• Prophylactic antibiotic at the time of induction

25. PRE-OPERATIVE PREPARATION
• Anaesthesia
• General anaesthesia with cuffed ET tube
• Adequate muscle relaxation
• Position
• Supine on a flat table with mild reverse Trendelenburg position.

26. SURGICAL TECHNIQUE
• Incision
• Midline or paramedian abdominal incision OR
• Chevron or rooftop incision (Self-retaining subcostal retractors)

27. SURGICAL TECHNIQUE
• Exploration
• Note any ascites and peritoneal deposits
• Explore from the pelvis to toward the stomach
• Examine the greater omentum, para-aortic and the lymph nodes of
the mesentery
• Examine the full length of the small and large bowel
• Draw the omentum caudally to examine the supracolic compartment

28. SURGICAL TECHNIQUE
• Exploration
• Examine the liver, adjacent diaphragm, gall bladder, free edge of lesser omentum.
• Examine the spleen, kidneys and adrenals
• Starting from the oesophageal hiatus and working distally, look and feel for the
tumour involvement, fixity, glands
• Avoid handling or squeezing the tumor if possible
• Examine the duodenum, pancreas and the coeliac axis

29. SURGICAL TECHNIQUE
• Mobilization and Resection
• The greater omentum is freed from the transverse colon
• Dissect out the gastro-epiploic nodes
• Doubly ligate and divide the right gastro-epiploic vessels

30. SURGICAL TECHNIQUE
• Mobilization and Resection
• Incise the anterior leaf above the pylorus
and towards the cardia
• The right gastric vessel and the
Suprapyloric nodes will be revealed
• Identify the right gastric and right gastro-
epiploic arteries

31. SURGICAL TECHNIQUE
• Duodenal Division
• Mobilize the 5 -6 cm of duodenum for division (Kochers manoeuvre)
• Transect the duodenum with a linear stapler 1cm distal to the pylorus
• For total gastrectomy – proximal limit is the gastro-oesophageal junction.

32. SURGICAL
TECHNIQUE
• Gastric Transection
• Divide the gastrosplenic ligament.
• Landmarks for Subtotal Gastrectomy
• 2nd short gastric artery along the
greater curvature
• 1 cm inferior to the
esophagogastric junction along
the lesser curvature

33. BILLROTH I RECONSTRUCTION
• A posterior row of interrupted seromuscular silk sutures between
the duodenum and the stomach
• The superior portion of the duodenal staple line is removed
• The gastric staple line is opened corresponding to duodenal
opening.
• A Posterior Mucosal layer continuous suturing with 3-0 Vicryl
• An Anterior Mucosal Layer continuous suturing with 3-0 Vicryl
• Anterior Seromuscular layer interrupted suturing with silk

35. BILLROTH II RECONSTRUCTION
• Choose a loop of the proximal jejunum
• The omega loop is pulled through the transverse colon mesentery
• Open the closure of the distal gastric remnant
• The posterior layers are sutured using use single stitches or a running suture
• For the anterior anastomosis, a running inverting suture is adequate
• An associated Braun's entero-enterostomy can be done to prevent bile reflux
• Side-to-side jejunostomy is done either with single stitches, a
• running suture, or a stapler device

36. BILLROTH II RECONSTRUCTION

37. BILLROTH II RECONSTRUCTION

38. BILLROTH II RECONSTRUCTION

39. BILLROTH II RECONSTRUCTION

42. ROUX-EN-Y RECONSTRUCTION
• The ligament of Treitz is identified
• Jejunum is dissected about 40–50cm distal to
Treitz’ ligament
• A retro-colic passage is made for the jejunum loop
• The distal loop is placed side-to-side to the
posterior wall of the gastric remnant.
• A side-to-side enteroenterostomy is then
constructed

43. RECONSTRUCTION AFTER TOTAL
GASTRECTOMY
• Loop esophagojejunostomy with entero-enterostomy
• Roux-en-Y reocnstruction
• Esophagojejunostomy Roux-en-Y configuration (end-to-side or end-to-.end)
• Esophagojejunostomy Roux-en-Y double tract configuration.
• Esophagojejunostomy with
• jejunal segment interposition by Longmire
• Colonic interposition

44. RECONSTRUCTION OPTIONS AFTER TOTAL
GASTRECTOMY
• Choose a loop of the proximal jejunum
• The omega loop is pulled through the transverse colon mesentery
• Open the closure of the distal gastric remnant
• The posterior layers are sutured using use single stitches or a running suture
• For the anterior anastomosis, a running inverting suture is adequate
• An associated Braun's entero-enterostomy is done between the loops pf jejunum

46. Roux-en-Y configuration
RECONSTRUCTION AFTER TOTAL
GASTRECTOMY

47. Roux-en-Y configuration
RECONSTRUCTION AFTER TOTAL
GASTRECTOMY

48. MODIFIED VERSIONS OF R-Y
RECONSTRUCTION
• RY configuration was modified by Hunt and Lawrence by creating a jejunal pouch
• Ω-pouch, S-pouch, and an aboral pouch

49. MODIFIED VERSIONS OF R-Y
RECONSTRUCTION
• Esophagojejunostomy Roux-en-Y double tract configuration

50. Esophagojejunostomy with jejunal
interposition

51. JEJUNAL
INTERPOSITION

52. POSTOPERATIVE CARE
1. Nurse patient in a propped-up position when conscious
2. Maintain NG tube and Keep NPO
3. IV Fluid Maintenance
4. Strict monitoring of fluid and electrolytes
5. IV antibiotics
6. IV analgesics and PPI
7. DVT Prophylaxis and Early Ambulation
8. Chest physiotherapy
9. Light diet can resume on POD 3

53. COMPLICATIONS
1. Early Complications
• Intra-gastric haemorrhage
• Extragastric haemorrhage
• Duodenal Blowout
• Stomal Obstruction
• Afferent loop obstruction
• Jejunal loop obstruction
• Gastric remnant necrosis
• Postoperative pancreatitis
• Common bile duct injury
• Omental infarction

54. COMPLICATIONS
1. Late Complications
• Dumping syndrome
• Recurrent ulcers
• Small gastric remnant syndrome
• Gastric remnant carcinoma
• Roux stasis syndrome
• Gastrojejunocolic fistula
• Chronic afferent loop obstruction
• Chronic efferent loop obstruction
• Internal hernia
• Jejunogastric intussusception

55. EARLY COMPLICATIONS
1. Dumping Syndrome
• Early Dumping (15 -30min after meals)
• Abrupt delivery of hyperosmolar load into the small bowel
• Diaphoretic, weak, light-headed, and tachycardic
• Crampy abdominal pain, Diarrhoea
• Treatment – Recumbency and Infusion of NS
• Late Dumping (2- 3hrs after meals)
• Reactive (post-prandial) hypoglycaemia
• Relieved with sugar (dextrose)

56. POSTGASTRECTOMY PROBLEMS
1. Treatment of Dumping Syndrome
a. Dietary management
• Avoids liquids during meals
• Avoid Hyperosmolar liquids (e.g., milk shakes)
• Encourage High fibre diets
b. Medical therapy
• Indicated if dietary measures are still inadequate
• SC Octreotide 100ug BD (can be increased to 500ug BD)
• α-glucosidase inhibitor (acarbose) – useful in late dumping
c. Operative management
• Roux-en-Y is the preferred choice

57. POSTGASTRECTOMY PROBLEMS
3. Gastric Stasis
• Mechanical cause
• anastomotic stricture, efferent limb kink from adhesions or constricting mesocolon, or a
proximal small-bowel obstruction).
• Functional cause
• Retrograde peristalsis in the Roux-limb
• Clinical features –
• vomiting of undigested food, bloating, epigastric pain, and weight loss.
• Investigation
• EGD, upper GI and small bowel series, gastric emptying scan, and gastric motor testing
• Treatment
• Dietary modification with promotility agents
• Intermittent oral antibiotics

58. POSTGASTRECTOMY PROBLEMS
3. Diarrhoea
• Dietary management +/-
• Some patient respond to codeine or loperamide
• Octreotide can also be started if symptoms are persistent

59. POSTGASTRECTOMY PROBLEMS
1. Bile Reflux Gastritis and Oesophagitis
• Gastritis component - ablation or resection of the pylorus
• Oesophageal component - Dysfunction of the cardia
• Nausea, bilious vomiting, and epigastric pain,

60. POSTGASTRECTOMY PROBLEMS
1. Roux syndrome
• Disruption of the antegrade contractions in the Roux limb
• Vomiting, epigastric pain, and weight loss
• Investigations
1. Endoscopy –
• Retained food or bezoars
• Dilation of the gastric remnant,
• Dilation of the Roux limb
2. Upper GI Series – delayed gastric motility (Confirmatory test)
3. GI motility testing – regrade propulsive activity

61. POSTGASTRECTOMY SYNDROMES
1. Roux syndrome
• Medical Treatment
1. Promotility agents
• Surgical Treatment Options
1. Paring down the gastric remnant (Gastric trimming)
2. Near total or Total Gastrectomy
3. Resection of Roux-limb (if dilated and flaccid) with
• Another Roux reconstruction
• Billroth II with Braun gastroenterostomy
• Henley loop

62. POSTGASTRECTOMY SYNDROMES
1. Afferent loop Syndrome
• Intrinsic or extrinsic obstructive process along the afferent limb or at the distal anastomosis
• Aetiology
• Post-operative adhesion
• Internal hernia
• Volvulus of the intestinal segment
• Kinking of the afferent limb at the gastrojejunostomy
• Scarring due to marginal (stomal) ulceration
• Treatment
• Conversion to a Roux-en-Y
• Billroth I reconstruction

63. Afferent loop Sydrome

64. POSTGASTRECTOMY SYNDROMES
1. Efferent Loop Syndrome
• Cause
• Herniation of limb behind the anastomosis
• Investigation
• Barium meal – failure of contrast to enter efferent loop
• Treatment
• Reducing the retro-anastomotic hernia and closing the retro-anastomotic space

65. POSTGASTRECTOMY PROBLEMS
1. Gallstones
• Vagal denervation causing gall bladder dysmotility and stasis.
• Treatment – Cholecystectomy during gastrectomy
2. Weight loss

66. POSTGASTRECTOMY PROBLEMS
1. Anaemia
• Reduced production of gastric acid and intrinsic factor
• Poor absorption of iron, B12 and folic acid
• Periodic assessment for iron and B12 deficiency
• Supplemental iron and B12
2. Bone Disease
• Malabsorption of Ca2+ and fat (including at soluble Vitamin D)
• Presents as pain and/or fractures years after the index operation
• Supplement Calcium and Vitamin D
• Periodic skeletal survey