Gastrectomy

A gastrectomy is a surgical procedure to remove all or part of the stomach. This procedure may be performed as part of weight-loss surgery, to manage ulcer disease or to treat stomach cancer.

When a gastrectomy is performed to treat stomach cancer—also called gastric adenocarcinoma—two approaches are commonly used, depending on the location of the cancer:

• Total gastrectomy, which removes the entire stomach
• Distal or subtotal gastrectomy, which removes the lower portion of the stomach

Unless the cancer has spread to other organs in the body (stage 4), most other stages of gastric cancer are treated with a gastrectomy. The goal of the operation is to remove all the cancer without any cancer cells being left at the edges (margins), while also trying to keep as much of the stomach as possible.

Before the procedure

Before surgery, you'll undergo a complete history and physical exam to make sure you’re healthy enough for the procedure. This will include blood tests and may include tests of the heart and lung functions. Because stomach cancer patients can be undernourished or underweight, a nutritional consultation may be done to see whether supplements are needed before or after surgery.

If you're on a medication to thin your blood, such as aspirin, you may be asked to stop taking these medications due to an increased risk of bleeding. You should ask the surgeon whether you may take your normal medications with a sip of water on the day of surgery. Because this procedure is performed under general anesthesia, you may need to follow instructions about when to stop eating and drinking. .

During the procedure

There are two approaches that may be offered by your surgeon for a gastrectomy, depending on the location of your tumor and other key factors:

• An open gastrectomy procedures is performed through one long incision through the belly.
• In some cases, a minimally invasive or robotic-assisted gastrectomy may be performed through small incisions, using an operating scope and other surgical instruments that fit through the incisions. The scope has a camera that sends images to a video screen in the operating room.

If you’re having a total gastrectomy, the surgeon will remove your entire stomach and nearby lymph nodes. In rare cases, if the tumor is invading into other organs, such as the colon or spleen, they may also be removed. The stomach may be separated from the esophagus and from the small intestine underneath. A flap of tissue that lies over the stomach, called omentum, may also be removed. If cancer has spread to nearby tissues above or below the stomach, these tissues may be removed. If cancer has reached the spleen, it is also removed. After your surgeon removes all the cancer and involved tissues, the end of the esophagus is attached to the end of the small intestine to create a new intestinal passage.

If you’re having a subtotal gastrectomy, either the upper or lower part of the stomach is removed, depending on the location of the tumor.

• If cancer is in the upper stomach, it’s called a proximal gastrectomy (a very rare procedure).
• If cancer is in the lower part, it’s called a distal gastrectomy.

Additionally, nearby lymph nodes will also be removed to help stage the cancer. The remaining part of the stomach is then attached either to the esophagus or small intestine.

After the procedure

The length of stay after the procedure will depend on the amount of stomach removed. You may be in the hospital from between three to seven days while you recover. If your entire stomach is removed, you may need a nasogastric tube inserted through the nose and into your intestine to drain fluids for a day or two. Until you’re able to eat and drink, you will receive fluids through an intravenous (IV) line. You'll initially be started on a liquid diet in the hospital and slowly advance to a soft diet. You should be able to start a light diet after the first week.

Pain is normal after a gastrectomy, and your care team may prescribe pain medication in order to control the discomfort. It may take several weeks to return to full activities, and you will be advised not to lift anything heavy for six weeks. You should avoid driving while on pain medication.

Diet is an important part of recovery. Because your stomach is smaller or had been removed, you'll have to eat differently. You'll meet with a dietitian while in the hospital to help ensure you’re getting proper nutrients and enough calories. It’s common to need dietary supplements, and many patients benefit from supplemental drinks. Because your stomach is smaller or completely removed, you may feel full soon after eating. Although the remaining tissues stretch over time, you'll need to eat small meals every few hours for several weeks until your diet has recovered. Fullness and eating smaller meals may lead to difficulty getting enough calories to maintain weight for several weeks after surgery, which is normal.

Because stomach cells help absorb vitamin B12, levels of this vitamin may get low after surgery and lead to anemia. You may need vitamin B12 injections.

What are the risks of a gastrectomy?

A gastrectomy is a major operation, and post-surgical complications are possible. Major risks of the surgery may include:

• Bleeding: The severity of bleeding depends on the source. If mild, you may be treated with a blood transfusion alone. Severe bleeding may require treatment with a repeat operation or intervention to stop the bleeding.
• Infection: An infection in the surgical incision area may require antibiotics or drainage.

Less commonly, the area where the ends of the organs are reconnected (an anastomosis) may not close properly. This may cause leaking of digestive fluids, or foods and liquids and may require treatment with drains placed by interventional radiologists to help the area heal, or even an additional operation by your surgeon. If the anastomosis narrows during the healing process due to scarring of the esophageal connection, this narrowing may lead to painful or difficulty passing food.

Other side effects and complications may develop during or after surgery, including:

• Lung problems: Surgery may cause you to avoid coughing and deep breathing. That may lead to loss of air in your lungs (atelectasis) or infection (pneumonia).
• Diarrhea: Because food may move more quickly through the upper digestive system after surgery, you may have a type of diarrhea called dumping syndrome.
• Pulmonary embolism: Blood clots that form in the legs may break loose and travel to the lungs, causing chest pain and difficulty breathing. Blood-thinning medications, compression stockings and frequent walking may help prevent those complications.
• Heartburn: A gastrectomy may make it easier for stomach acid to seep up into the swallowing tube (esophagus), causing heartburn. This side effect may be treated with antacids.

Once you return home, you also should watch out for complications and call your surgeon if you have:

• Fever
• Cough
• Diarrhea
• Heartburn
• Redness, swelling, pain or discharge at the incision areas
• Shortness of breath or difficulty breathing
• Pain, swelling or redness in the calf area