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Gastrectomy is the surgical removal of all or part of the stomach.
Gastrectomy is performed most commonly to treat the following conditions:
- stomach cancer
- bleeding gastric ulcer
- perforation of the stomach wall
- noncancerous polyps
Stomach cancer was the most common form of cancer worldwide in the 1970s and early 1980s, and the incidence rates have always shown substantial variation in different countries. Rates are currently highest in Japan and eastern Asia, but other areas of the world have high incidence rates, including Eastern European countries and parts of Latin America. Incidence rates are generally lower in Western Europe and the United States.
Gastrointestinal diseases (including gastric ulcers) affect an estimated 25–30% of the world's population. In the United States, 60 million adults experience gastrointestinal reflux at least once a month, and 25 million adults suffer daily from heartburn, a condition that may evolve into ulcers.
Gastrectomy for cancer
Removal of the tumor, often with removal of the surrounding lymph nodes, is the only curative treatment for various forms of gastric (stomach) cancer. For many patients, this entails removing not only the tumor, but part of the stomach as well. The extent to which lymph nodes should also be removed is a subject of debate, but some studies show additional survival benefits associated with removal of a greater number of lymph nodes.
Gastrectomy, either total or subtotal (also called partial), is the treatment of choice for gastric adenocarcinomas, primary gastric lymphomas (originating in the stomach), and the rare leiomyosarcomas (also called gastric sarcomas). Adenocarcinomas are by far the most common form of stomach cancer and are less curable than the relatively uncommon lymphomas, for which gastrectomy offers good chances of survival.
General anesthesia is used to ensure that the patient does not experience pain and is not conscious during the operation. When the anesthesia has taken hold, a urinary catheter is usually inserted to monitor urine output. A thin nasogastric tube is inserted from the nose down into the stomach. The abdomen is cleansed with an antiseptic solution. The surgeon makes a large incision from just below the breastbone down to the navel. If the lower end of the stomach is diseased, the surgeon places clamps on either end of the area, and that portion is excised. The upper part of the stomach is then attached to the small intestine. If the upper end of the stomach is diseased, the end of the esophagus and the upper part of the stomach are clamped together. The diseased part is removed, and the lower part of the stomach is attached to the esophagus.
After gastrectomy, the surgeon may reconstruct the altered portions of the digestive tract so that it may continue to function. Several different surgical techniques are used, but, generally speaking, the surgeon attaches any remaining portion of the stomach to the small intestine.
Gastrectomy for gastric cancer is almost always done using the traditional open surgery technique, which requires a wide incision to open the abdomen. However, some surgeons use a laparoscopic technique that requires only a small incision. The laparoscope is connected to a tiny video camera that projects a picture of the abdominal contents onto a monitor for the surgeon's viewing. The stomach is operated on through this incision.
The potential benefits of laparoscopic surgery include less postoperative pain, decreased hospitalization, and earlier return to normal activities. The use of laparoscopic gastrectomy is limited, however. Only patients with early-stage gastric cancers or those whose surgery is intended only for palliation (pain and symptomatic relief rather than cure) are considered for this minimally invasive technique. It can only be performed by surgeons experienced in this type of surgery.Gastrectomy for ulcers Gastrectomy is also occasionally used in the treatment of severe peptic ulcer disease or its complications. While the vast majority of peptic ulcers (gastric ulcers in the stomach or duodenal ulcers in the duodenum) are managed with medication, partial gastrectomy is sometimes required for peptic ulcer patients who have complications. These include patients who do not respond satisfactorily to medical therapy; those who develop a bleeding or perforated ulcer; and those who develop pyloric obstruction, a blockage to the exit from the stomach.
Before undergoing gastrectomy, patients require a variety of such tests as x rays, computed tomography (CT) scans, ultrasonography, or endoscopic biopsies (microscopic examination of tissue) to confirm the diagnosis and localize the tumor or ulcer. Laparoscopy may be done to diagnose a malignancy or to determine the extent of a tumor that is already diagnosed. When a tumor is strongly suspected, laparoscopy is often performed immediately before the surgery to remove the tumor; this method avoids the need to anesthetize the patient twice and sometimes avoids the need for surgery altogether if the tumor found on laparoscopy is deemed inoperable.
After gastrectomy surgery, patients are taken to the recovery unit and vital signs are closely monitored by
To remove a portion of the stomach in a gastrectomy, the surgeon gains access to the stomach via an incision in the abdomen. The ligaments connecting the stomach to the spleen and colon are severed (B). The duodenum is clamped and separated from the bottom of the stomach, or pylorus (C). The end of the duodenum will be stitched closed. The stomach itself is clamped, and the portion to be removed is severed (D). The remaining stomach is attached to the jejunum, another portion of the small intestine (E).
The nursing staff until the anesthesia wears off. Patients commonly feel pain from the incision, and pain medication is prescribed to provide relief, usually delivered intravenously. Upon waking from anesthesia, patients have an intravenous line, a urinary catheter, and a nasogastric tube in place. They cannot eat or drink immediately following surgery. In some cases, oxygen is delivered through a mask that fits over the mouth and nose. The nasogastric tube is attached to intermittent suction to keep the stomach empty. If the whole stomach has been removed, the tube goes directly to the small intestine and remains in place until bowel function returns, which can take two to three days and is monitored by listening with a stethoscope for bowel sounds. A bowel movement is also a sign of healing. When bowel sounds return, the patient can drink clear liquids. If the liquids are tolerated, the nasogastric tube is removed and the diet is gradually changed from liquids to soft foods, and then to more solid foods. Dietary adjustments may be necessary, as certain foods may now be difficult to digest. Overall, gastrectomy surgery usually requires a recuperation time of several weeks.
Overall survival after gastrectomy for gastric cancer varies greatly by the stage of disease at the time of surgery. For early gastric cancer, the five-year survival rate is as high as 80–90%; for late-stage disease, the prognosis is bad. For gastric adenocarcinomas that are amenable to gastrectomy, the five-year survival rate is 10–30%, depending on the location of the tumor. The prognosis for patients with gastric lymphoma is better, with five-year survival rates reported at 40–60%.
Depending on the extent of surgery, the risk for postoperative death after gastrectomy for gastric cancer has been reported as 1–3% and the risk of non-fatal complications as 9–18%. Overall, gastric cancer incidence and mortality rates have been declining for several decades in most areas of the world.
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