What is a gastrectomy?
A partial gastrectomy is the surgical removal of a portion of the stomach, as opposed to a total gastrectomy in which the entire stomach is removed. A gastrectomy may also be accompanied by a vagotomy (removal of the part of the vagus nerve that stimulates the stomach’s acid production for digestion).
A partial gastrectomy is most often accompanied by a surgery to create a connection (anastomosis) between the remaining portion of the stomach and the small intestine’s beginning (duodenum) or middle (jejunum) portion. It depends on where the particular disease is and how much of the gastrointestinal tract is removed.
A partial gastrectomy may be
- Antrectomy: removal of the lower 30% of the stomach
- Hemigastrectomy: removal of 50% of the stomach
- Subtotal gastrectomy: removal of 80% of the stomach
Gastrectomy history and development
The earliest partial gastrectomies performed in the 19th century were unsuccessful. The first successful partial gastrectomy was performed in 1881 for pyloric cancer (cancer in the lower part of stomach opening into the small intestine).
Partial gastrectomies were originally performed using the conventional method with a large incision. Subsequently, advancements in imaging technology and surgical techniques, led to development of several minimally invasive methods.
What are the surgical techniques used in partial gastrectomy?
A partial gastrectomy may be performed using one of the following methods:
- Open surgery: The surgeon makes a long, upper midline incision and uses surgical tools typical for performing open abdominal surgeries.
- Laparoscopic surgery: The surgeon makes a single, small incision at the navel (umbilicus) or five tiny incisions in the stomach region. The surgeon then performs the procedure with tiny surgical tools inserted through a flexible tube with a lighted camera (laparoscope).
- Laparoscopic wedge resection: The surgeon removes a wedge-shaped portion of the stomach laparoscopically.
- Robotic laparoscopic surgery: A robot operates the tiny surgical tools in the laparoscope. The surgeon uses a computer terminal to direct and control the robotic equipment.
Non-exposed endoscopic wall-inversion surgery (NEWS): A newly developed technique that involves a single incision at the umbilicus for the laparoscopic instruments, assisted by an endoscope (flexible tube with a lighted camera inserted through the nose into the stomach).
The minimally invasive methods are aimed at achieving precision of procedure with minimal blood loss and trauma to the patient, but may not be appropriate for all conditions. In some situations the surgeon may even have to convert a laparoscopic surgery into an open surgery.
Why is a partial gastrectomy performed?
A partial gastrectomy is most often performed to treat stomach cancer. A partial gastrectomy may be indicated in the following situations:
Gastric cancer
- Subtotal gastrectomy of the lower stomach is performed for cancer in the antrum and pylorus (the lower parts of stomach attached to the small bowel).
- Total gastrectomy is performed for cancer in the upper or main part of the stomach.
- Partial gastrectomy of the upper stomach and partial esophagectomy (removal of esophagus) is performed for cancer in the esophagogastric junction (the place where esophagus is attached to the stomach).
Recurrent ulcer disease: Recurrence of ulcers have become uncommon, with advancement in treatment of ulcers with medications for acid reduction, and eradication of Helicobacter pylori (a bacteria species that causes ulcers). Partial gastrectomy is now a rare treatment for ulcer.
Large duodenal perforations: A partial gastrectomy of the lower stomach may be performed when there are large perforations in the duodenum that cannot be patched. The perforated part of the duodenum is removed and the remaining portion is connected to the main part of the stomach.
Bleeding gastric ulcers: Partial gastrectomy may be performed when there are bleeding ulcers in the stomach.
Gastrointestinal stromal tumors: Partial gastrectomy may be required to remove large stromal tumors (gastrointestinal tract tumors that may be benign or malignant) in the stomach.
Corrosive stricture of the stomach: Partial gastrectomy is performed to treat strictures caused primarily in the esophagus and the stomach after ingestion of any corrosive substance.
Morbid obesity: A subtotal gastrectomy, also known as a sleeve gastrectomy, is performed to reduce the size of the stomach in people with life-threatening obesity. A small pouch is left remaining which is connected to the duodenum or jejunum.
Partial gastrectomy is performed with caution in patients with
- Anemia
- Hypoproteinemia (low protein levels in blood)
- Hypokalemia (low potassium in blood)
- Severe comorbidities (co-existence of more than one disorder)
- Severe ascites (fluid in the abdomen)
- Metastasized (spread from original site) cancer
- Cancer in the peritoneum (abdominal membrane)
- Tumors fixed to the adjacent organs such as liver or pancreas
- Adhesions from previous abdominal surgeries
The patient may have to undergo corrective treatments where possible, prior to surgery. In some patients with metastasized cancer, a partial gastrectomy may be performed as a palliative measure to relieve symptoms.
Patients with malignancy may undergo an exploratory laparoscopy before a planned partial gastrectomy. The reason is to assess the stage of the cancer, and presence of metastasis in the peritoneum or liver.