Subtotal Gastrectomy

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SAMPLE EXCERPT
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PRE-PROCEDURE
INDICATIONS
  • Gastric neoplasia
  • Recurrent ulcerations after truncal vagotomy and antrectomy
CONTRAINDICATIONS
  • Ascites (relative)
  • Unless indicated for palliation, gastrectomy is not performed in the presence of:
    • Peritoneal disease
    • Hepatic metastases
    • Diffuse nodal metastases
EQUIPMENT
  • Anesthetic equipment
  • Operating table
  • Instrument table
  • Electrocautery device
ANATOMY
  • The cardia connects the proximal stomach to the distal esophagus.
  • The pylorus connects the distal stomach to the proximal duodenum.
  • From proximal to distal, the stomach is divided in three regions: fundus, corpus and antrum.
  • Inferiorly, the stomach is attached to the transverse colon, spleen, caudate lobe of the liver, diaphragmatic crura, and retroperitoneal nerves and vessels. The gastrosplenic ligament attaches the proximal greater curvature to the spleen.
  • Most of the blood supply to the stomach is from the celiac artery. There are four main arteries: the left and right gastric arteries along the lesser curvature and the left and right gastroepiploic arteries along the greater curvature. The largest artery to the stomach is the left gastric artery. There are extensive anastomotic connections between these major vessels. In general, the veins of the stomach parallel the arteries.
  • The lymphatic drainage of the stomach parallels the vasculature and drains into four zones of lymph nodes. All four zones of lymph nodes drain into the celiac group and into the thoracic duct. Gastric cancers may metastasize to any of the four nodal groups regardless of the cancer location.
  • The extrinsic innervation of the stomach is both parasympathetic through the vagus and sympathetic through the celiac plexus.

PROCEDURE
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  • Step-by-step text instructions for performing the procedure
  • Clinical pearls providing practical clinical tips from medical experts
  • Patient safety guidelines consistent with Joint Commission and OHSA standards
  • Links to medical evidence and related procedures

POST-PROCEDURE
CARE
  • Pain control with IV analgesia
  • Progressive increase in activity
  • Liquid intake usually started on the third postoperative day
COMPLICATIONS
  • Bleeding
  • Gastric stasis
  • Postoperative pancreatitis
  • Dumping syndrome
  • Anastomotic leak in the area of the gastroduodenostomy or duodenal stump
  • Chronic gastritis
  • Enterogastric reflux
  • Anastomotic narrowing or obstruction
  • Recurrent tumor
  • Small bowel obstruction
  • Afferent loop obstruction
RESULT ANALYSIS
  • Studies report a mortality of 1% to 2% for partial gastric resections for an uncomplicated gastric ulcer, independent of the mode of reconstruction. Mortality tends to be higher in emergency surgery for complicated ulcer. Ulcers recur in less than 4% of patients, and serious postgastrectomy problems are observed in 3% to 5% of patients.
  • Regardless the type of gastrectomy, it seems that a D2 node dissection with at least 15 sampled nodes should be performed for gastric adenocarcinoma.
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