Perioperative management - Subtotal gastrectomy, type Billroth II with Roux-en-Y reconstruction

The article demonstrates the subtotal gastrectomy for a neoplasm in the distal third of the stomach.

Total gastrectomy, which was long considered the standard for the treatment of gastric carcinoma, has no advantage over an R0 resection through a subtotal gastrectomy.

When selecting the extent of resection, the tumor location is primarily decisive:

• Carcinoma in the distal third of the stomach → subtotal 4/5 resection
• Carcinoma in the middle third → gastrectomy
• Carcinoma in the proximal third with involvement of the cardia → extended gastrectomy with transhiatal resection of distal esophageal segments

Other indications for a total gastrectomy:

• Linitis plastica, a special form of gastric carcinoma that leads to diffuse infiltration of the stomach wall (usually signet ring cell carcinoma)
• Carcinomas affecting multiple anatomical subregions (upper, middle, and lower third of the stomach).

In addition to tumor location, the histomorphological classification of gastric carcinoma according to Laurén also plays a role in selecting the resection margins:

• Diffuse carcinoma type: oral safety margin 5 – 8 cm in situ, i.e., more than 5 cm on the fresh specimen without tension
• Intestinal carcinoma type: oral safety distance 4 – 5 cm, i.e., 2 – 3 cm on the fresh specimen

Considering the oral safety distances, a subtotal distal resection is generally sufficient for diffuse carcinoma in the lower third of the stomach and for the intestinal type in the lower and middle thirds of the stomach, while gastrectomy is indicated in all other cases.

Endoscopic resection of early gastric carcinomas

Superficial early gastric carcinomas confined to the mucosa (T1aN0M0) can be resected endoscopically, as the risk of lymph node metastasis is 0 – 2%. However, if the superficial parts of the submucosa are already affected, the rate of lymph node metastases increases to 25%.

According to the Japanese classification of gastric carcinomas, endoscopic submucosal resection can be performed for mucosal carcinomas with:

• Lesions < 2 cm of the elevated type,
• Lesions < 1 cm of the flat type,
• No ulceration,
• Histological differentiation grade good to moderate (G1–G2).

The goal is an en-bloc R0 resection while maintaining safety margins depending on tumor histology (intestinal type: 4 – 5 cm, diffuse type: 5 – 8 cm). Patients with Helicobacter pylori colonization should receive eradication treatment.

Relevant comorbidities with surgical or anesthesia incapacity.

Palliative situations

The current S3 guideline for the surgery of gastric carcinoma has issued consensus-based statements for symptomatic tumor stenosis, tumor bleeding, and the treatment of metastases based on existing studies:

Tumor stenosis

• Stent implantation, gastroenterostomy, jejunal feeding tube, or palliative radiation
• palliative resection: only in exceptional cases, as there is no sufficient evidence

Tumor bleeding

• endoscopic hemostasis; if not possible or ineffective:
• angiographic embolization
• palliative resection as a last resort
• chronic oozing bleeding: palliative radiation

Metastases
Currently, there is insufficient evidence for the effectiveness of surgical measures for metastases in terms of survival. In individual cases, resection of isolated organ metastases (liver, ovary) without the presence of peritoneal carcinomatosis may be considered.

mandatory:

• Esophagogastroduodenoscopy with biopsy samples
• Endosonography should be part of the staging of the primary tumor in patients with curative therapy intention.
• Ultrasound of the abdomen to exclude liver metastases
• CT thorax/CT abdomen for classification of the M category

optional:

• Tumor markers (CA 72-4, CA 19-9, CEA)
• MR abdomen (magnetic resonance imaging) should be reserved for patients who cannot undergo CT.
• A peritoneal lavage with cytology can be performed to complement staging.
• Laparoscopy in locally advanced tumors (T3/4) to exclude extensive peritoneal carcinomatosis or for M categorization, possibly plus IOUS (intraoperative ultrasound) and PE (biopsy)

• If necessary, initiate a preoperative nutritional therapy for patients who have significantly lost weight preoperatively.
• Special laxative measures are not required. The patient should only be kept fasting preoperatively as required by anesthesiology (minimum 2 – 6 hours).
• Blood group determination; provision of erythrocyte concentrates

General Surgical Risks:

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

Specific Surgical Risks:

• Final decision on the resection procedure only intraoperatively
• Injury to internal vessels and organs, e.g., spleen, bile duct
• Anastomotic insufficiency
• Duodenal stump insufficiency
• Endoluminal/intra-abdominal bleeding
• Intra-abdominal abscess, peritonitis
• Pancreatitis or pancreatic fistulas
• Wound healing disorder
• Incisional hernia

Possible Necessary Extension of the Procedure:

• Cholecystectomy
• Resection of liver metastases
• Splenectomy (Note: If an indication for splenectomy arises during a planned subtotal gastrectomy, e.g., due to a splenic lesion, a total gastrectomy is usually required!)

Indications of:

• Temporary weight loss
• Changed eating habits
• Drains, gastric tube, urinary diversion
• Possible blood transfusion