Partial Gastrectomy for Stomach Cancer

Dealing with stomach (or gastric) cancer can be a challenging experience, and depending on your diagnosis, a partial gastrectomy may be recommended as a treatment option. It is a surgical procedure that involves removing part of the stomach. It is a major decision that can be overwhelming, but understanding the process and the different types of surgery available can help you prepare better for what lies ahead. By doing so, you can have a clearer idea of what to expect and make informed decisions about your treatment.

Often performed as part of gastric cancer treatment, a gastrectomy is a surgical procedure where all or part of the stomach is removed. Depending on the location of the cancer in your stomach, your doctors will decide which kind of gastrectomy you need to treat your type of gastric cancer.

Gastrectomies can be classified into two broad categories: partial gastrectomy and total gastrectomy. This article will focus on partial gastrectomy.

The term “partial gastrectomy” is broad and essentially involves any surgical procedure where only a part of the stomach is removed. This category can be further broken down into three types of procedures: a wedge gastrectomy, proximal gastrectomy and subtotal (distal) gastrectomy.

Wedge gastrectomy

In this operation, a wedge-shaped section of the stomach containing the gastric tumor is locally removed while leaving most of the stomach intact. Also known as a wedge resection, it is typically used to treat gastrointestinal stromal tumors (GISTs) of the stomach.

Proximal gastrectomy

Proximal gastrectomy involves the removal of the upper (proximal) part of the stomach and nearby lymph nodes. This surgery is usually performed for early gastric cancers of the proximal stomach (clinically node-negative and T1 tumor). If a proximal stomach tumor is advanced, a total gastrectomy will be performed instead because more extensive lymph node dissection needs to be performed.

There are various methods of reconstruction after a proximal gastrectomy. One method of reconstruction is to perform an esophago-gastric (OG) anastamosis, where the remnant stomach is connected to the esophagus. However, this method of reconstruction may be associated with significant reflux.

Another technique of anastamosis after a proximal gastrectomy is the double-track reconstruction. In this approach, after performing an esophago-jejunal anastamosis with a loop of small bowel (jejunum), your surgeons will connect the remaining part of the stomach to the Roux limb, creating a gastrojejunostomy (GJ). Double-track reconstruction has the benefit of reducing the risk of reflux, anemia and vitamin B12 deficiency after a proximal gastrectomy.

Subtotal (Distal) gastrectomy

This operation involves the removal of the lower (distal) half of the stomach, draining lymph nodes and part of the omentum. Any affected organs surrounding the stomach, such as the spleen, may also be resected if there is direct tumor invasion in an effort to eradicate the cancer completely.

The location of your gastric tumor will determine how much of the stomach will be removed. If the cancer is positioned at the antrum, your surgeons may remove the distal stomach, which makes up about 25 to 40% of the entire stomach. If the tumor is larger and affects the majority of the distal stomach, removal of at least 75% of the entire stomach is required in what is known as a (distal) subtotal gastrectomy.

Subsequently, the remaining portion of the stomach is joined to the small intestine. Reconstruction of the GI tract ensures that food can continue to move through the digestive system. Three reconstruction techniques are commonly used following a distal (subtotal) gastrectomy, which are:

• Billroth I gastroduodenostomy: A reconstruction technique that involves connecting the remaining part of the stomach with the duodenal stump. This is known as a gastroduodenostomy.
• Billroth II gastrojejunostomy: A reconstruction technique that involves joining the remaining section of the stomach to the side of the proximal jejunum in what is known as a gastrojejunostomy.
• Roux-en-Y reconstruction: In this reconstruction technique, a cut is first made across the jejunum to create two distinct segments. One segment, called the biliopancreatic limb, consists of the duodenum and the proximal jejunum. The other segment, which comprises the distal jejunum followed by the rest of the small intestine, is known as the Roux limb. Next, the remaining stomach is connected to the Roux limb (gastrojejunostomy). The biliopancreatic limb is then joined to the distal part of the Roux limb to create a jejunojejunostomy.

The choice of reconstruction technique depends on many factors and should be discussed with your surgeon.

Regardless of the type of partial gastrectomy you receive, your surgeons will likely remove lymph nodes that are near your stomach. This is called a lymph node dissection or lymphadenectomy. The aim of performing a lymphadenectomy is to reduce the risk of your gastric cancer coming back in the future, seeing that some of these lymph nodes could be cancerous. Moreover, your doctors will examine these lymph nodes to find out how far your cancer has spread and determine the stage of the cancer. This helps the doctors to determine the prognosis and guide decisions regarding subsequent treatment options.

A partial gastrectomy can be done in different settings for different purposes, which include:

• Curative gastrectomy: Surgery that is done with the aim of removing the gastric tumor and curing your cancer is called a curative gastrectomy. This type of treatment involves completely removing the cancerous part of the stomach with a sufficient resection margin, and nearby lymph nodes around the tumor.
• Palliative gastrectomy: If the cancer is too widespread and cannot be removed completely, surgery may still be performed with the intent to relieve symptoms but not to cure. This is known as palliative gastrectomy. This may be performed in cases where the tumor bleeding occurs despite radiotherapy.