Total gastrectomy

The first successful total gastrectomy (TG) for cancer was performed in 1897, 16 yr after Billroth's historic pylorectomy, by Swiss surgeon Carl Schlatter. This procedure involves removing the entire stomach from the distal esophagus to the proximal duodenum. TG is performed in many major medical centers for the treatment of gastric cancer. The primary indications for TG is to obtain a minimum of a 5-cm proximal margin for large tumors or the body, fundus and /or cardia of the stomach, or with tumors growing in a diffuse pattern (linitis plastica). The proximal margin length is best determined and should be recorded at the initial endoscopy. This is particularly important for lesions arising from the lesser curve.

After diagnostic endoscopy, a CT of the abdomen must be done to rule out the presence of metastatic disease, and to evaluate the possible extent of resection. The presence of metastatic disease is a relative contraindication to performing a TG because most patients can be palliated with chemotherapy.

After removing the entire stomach, reconstruction with the proximal jejunum creating a Roux-en-Y limb (Fig. 2) is the most commonly performed technique. Common variations seen with reconstruction involve the construction of a jejunal pouch. Improvements in oral intake and better weight gain have been attributed to using a pouch. There have been at least six randomized controlled trials evaluating various surgical reconstruction techniques following total gastrectomy (17-22), and no clear conclusion can be drawn regarding the optimal reconstruction technique. These trials suffer from either small sample size, varied use of nonstandard quality of life indexes, and/or they lack appropriate controls. Efforts continue to design simple, effective, and physiologic means of reconstructing the GI tract.

Postoperative radiographic evaluation (Fig. 3) is commonly performed to rule out an anastomotic leak (Fig. 4) between the fifth and seventh postoperative day. Because clinical signs will usually precede a clinically significant anastomotic leak in most instances, a gastrografin swallow can be used selectively to confirm clinical suspicion.

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