Perioperative management - Partial gastrectomy with Roux-en-Y gastrojejunostomy

The tutorial demonstrates partial gastric resection in cancer of the distal third of the stomach.

Total gastrectomy, which had long been considered the procedure of choice in gastric cancer, does not offer any benefit over R0 resection by partial gastric resection.

When defining the extent of resection, the location of the tumor will be of overriding importance.

• Cancer in the distal third of the stomach → partial (four-fifths) resection
• Cancer in the middle third → gastrectomy
• Cancer in the proximal third with cardiac involvement → extended gastrectomy with transhiatal segmental resection of the distal esophagus

Other indications for total gastrectomy:

• Linitis plastica, a special variant of gastric cancer resulting in diffuse invasion of the gastric wall (mostly signet ring cell carcinoma)
• Cancer affecting several anatomical regions of the stomach (proximal, middle and distal third)

Defining the resection limits has to take into account not only the tumor site but also the histomorphological Laurén classification of gastric cancer:

• Diffuse type of cancer: Proximal margin 5 – 8 cm in situ, i.e., on fresh specimen without traction more than 5 cm
• Intestinal type of cancer: Proximal margin 4 – 5 cm, i.e., 2 – 3 cm on fresh specimen

Thus, in diffuse type of cancer in the distal third of the stomach and in the intestinal type in the middle and distal third of the stomach, partial distal resection usually suffices, while gastrectomy is indicated in all other cases.

Endoscopic resection of early gastric cancer

Superficial early cancer limited to the gastric mucosa (T1aN0M0) can be resected endoscopically because the risk of lymphatic spread is 0 – 2 %. If, on the other hand, the superficial region of the submucosa has already been invaded, the rate of lymph node metastasis jumps to 25 %.

According to the Japanese classification of gastric cancer, endoscopic submucosal resection may be performed in mucosal cancer, if:

• Lesion diameter < 2 cm, elevated type
• Lesion diameter < 1 cm, flat type
• No ulceration
• Histology: Well to moderately differentiated (G1-G2)

The aim is the en-bloc-R0-resection respecting the margins required by the histology of the tumor (intestinal type: 4 – 5 cm, diffuse type: 5 – 8 cm). Patients with helicobacter pylori colonization should be eradicated first.

Significant comorbidity with patient unfit for anesthesia and/or surgery

Palliation

For symptomatic stenosis, bleeding and metastasis of the tumor, the current German S3 guideline on gastric cancer surgery offers these consensus statements based on published trials:

Tumor stenosis

• Stenting, gastroenterostomy, jejunal feeding tube or palliative radiotherapy
• Palliative resection: Only in exceptional cases, since there is insufficient evidence

Tumor bleeding

• Endoscopic hemostasis; if not possible or ineffective:
• Angiographic embolization
• Palliative resection as a measure of last resort
• Chronic seepage: Palliative radiotherapy

Metastases

Regarding survival, there is insufficient evidence at present for the effectiveness of surgery in metastatic spread. In individual cases, resection of isolated organ metastases (liver, ovaries) may be considered in the absence of peritoneal spread.

Mandatory:

• Esophagogastroduodenoscopy with biopsies
• In patients considered for curative management, primary tumor staging should include endosonography
• Abdominal ultrasound to rule out metastases
• Thoracic/abdominal CT scans for M staging

Optional:

• Tumor markers (CA 72-4, CA 19-9, CEA)
• Abdominal MRI (magnetic resonance imaging) should be reserved for those patients unable to undergo CT scanning
• Possibly peritoneal lavage with cytology to complement staging
• Laparoscopy in locally advanced tumors (T3/4) to rule out extensive peritoneal spread or M staging, possibly incorporating IOUS (intraoperative ultrasound) and exploratory biopsy

• In patients with significant weight loss before surgery, preoperative nutrition therapy may be initiated, if needed.
• Special laxative measures are not required. As required by the anesthetists, the patient should have nothing by mouth before surgery (for at least 2 – 6 hours).
• Blood grouping; packed RBCs on call

General risks

• Thromboembolism
• Pneumonia
• Heparin intolerance, HIT
• Urinary tract infection

Special surgical risks:

• Final decision on the type of resection only during the procedure
• Injury of internal vessels and organs, e.g., spleen, bile duct
• Anastomotic failure
• Duodenal stump failure
• Endoluminal/ intraabdominal bleeding
• Intraabdominal abscess, peritonitis
• Pancreatitis and pancreatic fistulas
• Secondary healing
• Incisional hernia

Possible extension of the procedure:

• Cholecystectomy
• Resection of liver metastases
• Splenectomy (Note: If during planned partial gastrectomy splenectomy is indicated, e.g., injury to the spleen usually requires total gastrectomy!)

Information on:

• Temporary weight loss
• Changes in eating habits
• Drains, nasogastric tube, urinary catheter
• Possibly allogeneic blood transfusions

General anesthesia
Intraoperative and postoperative analgesia with epidural catheter

Follow these links to PROSPECT (Procedures Specific Postoperative Pain Management) and the current German guideline Leitlinien der Behandlung akuter perioperativer und posttraumatischer Schmerzen [Guidelines on the treatment of acute perioperative and posttraumatic pain].

• Supine
• Right arm adducted
• Left arm abducted

• Surgeon on right side of patient
• First assistant on left side facing surgeon
• Second assistant on right side of patient craniad of surgeon
• Scrub nurse on left side of patient caudad of first assistant

In addition to the basic abdominal surgical instrument sets, the following additional instruments are needed:

• Abdominal wall retractor system
• Surgical vessel loops to occlude, retract and identify anatomically important structures
• Linear cutters with different magazine lengths for closing both the duodenal and proximal gastric stump
• Bipolar scissors

Postoperative analgesia

• Continue epidural anesthesia postoperatively for 2–5 days

Follow these links to PROSPECT (Procedures Specific Postoperative Pain Management) and the current German guideline Leitlinien der Behandlung akuter perioperativer und posttraumatischer Schmerzen [Guidelines on the treatment of acute perioperative and posttraumatic pain].

Postoperative care

• Monitoring on the intensive care unit (at least for 24 hours)
• Remove targeted intraabdominal drains depending on their volume drained
• Optionally, an upper GI series or endoscopic examination of the anastomosis may be performed on postoperative day 5–7
• Remove skin sutures on postoperative day 10–12
• Splenectomy: Vaccination against streptococcus pneumoniae, haemophilus influenzae and meningococci!

Deep venous thrombosis prophylaxis
Unless contraindicated, the moderate risk of thromboembolism (surgical operating time > 30 minutes) calls for prophylactic physical measures and low-molecular-weight heparin, possibly adapted to weight or dispositional risk, until full ambulation is reached. Note: Renal function, HIT II (history, platelet check).
This link will provide you with the current German guidelines: Thromboembolieprophylaxe

Ambulation

• Speedy mobilization

Physical therapy

• Breathing exercises

Diet

• Aim for return to enteral nutrition as quickly as possible; until then, parenteral nutrition and fluid replacement.

Bowel movement:

• Laxatives may have to be started on postoperative day 2

Work disability

• Usually, patient will be unable to return to work for at least 4 weeks.