Partial Gastrectomy and Gastrointestinal Reconstruction

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Partial gastrectomy and gastrointestinal reconstruction

Author: Pamela Hebbard, MD, FRCS
Section Editor: David I Soybel, MD
Deputy Editor: Wenliang Chen, MD, PhD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Oct 2021. | This topic last updated: Feb 08, 2021.
INTRODUCTION
Partial gastric resection is used to treat cases of benign gastric disease for which resection is
indicated; to treat malignant gastric tumors, such as adenocarcinoma, where sufficient margins
can be achieved; to treat selected cases of gastrointestinal stromal tumor (GIST); and to manage
complications related to conservative management lymphomas. The first antrectomy for gastric
cancer was performed by Ludwik Rydygier in 1880 [1]. The patient lived for 12 hours, passing
away from postoperative shock. The first antrectomy in which the patient survived the
operation was performed by Theodor Billroth in 1881 [1]. The patient subsequently passed away
from metastatic disease. Antral resection was felt by many to be too severe for the treatment of
benign disease, but partial gastrectomy became the treatment of choice for ulcer disease after
a seminal paper was published in 1910 [1,2]. However, surgery is uncommonly needed in the
era of modern antiulcer therapies, being reserved predominantly for complications or refractory
disease.
The extent of gastric resection and type of reconstruction chosen impacts the nature of
perioperative and later complications, particularly the development of postgastrectomy
syndromes. In Japan and other countries where the incidence of early gastric cancer is common,
function-preserving techniques, including pylorus-preserving segmental gastrectomy (PPSG)
and vagus nerve preservation, have been promoted. The role of these techniques in treating
patients in North America has not been well studied. A variety of options following partial
gastrectomy are available to restore gastrointestinal continuity, the most common of which are
the Billroth I, Billroth II, and Roux-en-Y reconstructions.
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The indications and techniques for partial gastric resection and reconstruction, perioperative
care, and complications will be reviewed here. The diagnosis and management of pathologies
that may indicate the need for partial gastric resection are discussed in separate topic reviews.
Total gastrectomy and reconstruction are discussed separately. (See "Total gastrectomy and
gastrointestinal reconstruction".)
SURGICAL ANATOMY AND PHYSIOLOGY OF THE STOMACH
The stomach is located in the left upper quadrant of the abdomen. Anteriorly, the stomach is
related to the left lateral lobe of the liver, diaphragm, colon, omentum, and anterior abdominal
wall ( figure 1). Posteriorly, the stomach is associated with the pancreas, spleen, left kidney
and adrenal gland, splenic artery, and left diaphragm ( figure 2 and figure 3).
The stomach is divided anatomically into five sections, with each section based upon histologic
differences and with each having a unique role in the process of digestion ( figure 4). These
sections include [3] (see "Physiology of gastric acid secretion"):
● Cardia – The proximal portion of the stomach adjacent to the lower esophageal sphincter.
It contains mucus neck cells and endocrine cells.
● Fundus – The portion of the stomach that rises above the level of the cardiac opening. It
contains parietal cells, chief cells, endocrine cells, and mucus neck cells.
● Body – The portion of the stomach that lies between the fundus and the antrum. It
contains cell types that are similar to the fundus.
● Antrum – The distal portion of the stomach demarcated from the body of the stomach on
the lesser curvature by the angular incisura. It contains pyloric glands, endocrine cells,
mucus neck cells, and G cells.
● Pyloric sphincter – A thick muscular valve separating the antrum from the duodenum. It
contains mucus neck cells and endocrine cells.
The blood supply to the stomach is predominantly derived from the branches of the celiac
artery ( figure 1). The left gastric artery, which is derived from the celiac artery, courses along
the lesser curvature of the stomach and anastomoses with the right gastric artery, which is a
branch of the common hepatic artery. The right and left gastroepiploic arteries arise from the
gastroduodenal artery and splenic arteries, respectively, and anastomose along the greater
curvature. The short gastric arteries arise from the splenic artery and supply the fundus of the
stomach. The gastric veins (left and right) parallel the arterial supply draining into the portal
vein.
Lymphatic drainage — For patients with gastric cancer, lymphadenectomy is performed in

concert with the gastric resection. The lymph node stations ( table 1), as defined by the
Japanese Gastric Cancer Association, are grouped according to location ( figure 5) and follow
the extent of potential lymph node dissection (D1 through D4) [4]. (See 'Lymph node dissection'
below.)
● Perigastric lymph nodes – Refers to lymph nodes attached directly to the stomach along
the greater and lesser curvatures
● Perivascular lymph nodes – Refers to lymph nodes along the gastric (left and right),
gastroepiploic, hepatic (left and right), celiac, splenic, or mesenteric vessels
● Peripyloric – Refers to lymph nodes above and below the pylorus
● Peripancreatic – Refers to lymph nodes in the region of the pancreas
● Periaortic – Refers to lymph nodes in the vicinity of the aorta
TERMINOLOGY
The term "partial gastrectomy" is broad and encompasses essentially any procedure that does
not remove the entire stomach. Partial gastrectomy can be proximal or distal. Distal
gastrectomy can be performed to remove only the antrum, the distal two-thirds of the stomach,
the distal four-fifths, or nearly the entire stomach as a subtotal gastrectomy. Other types of
gastrectomy include wedge resection, mucosal/sleeve resection, and pylorus-preserving
segmental gastrectomy. (See 'Resection techniques' below.)
Total gastrectomy refers to removal of the entire stomach including the gastroesophageal
junction and pylorus. Total gastrectomy is discussed elsewhere. (See "Total gastrectomy and
INDICATIONS
Partial gastrectomy may be indicated in the treatment of various stomach diseases both
malignant and benign or, rarely, in the management of devascularization injuries of the
stomach due to trauma, or other insults.
Malignant tumors — Whether partial gastrectomy is appropriate for the management of

malignant tumors of the stomach depends upon the ability to control local disease by obtaining
an appropriate margin [5]. In patients with malignant tumors, partial gastric resection and
reconstruction may be indicated primarily, in combination with neoadjuvant therapy [6], to
manage complications, or, in select circumstances, to treat tumor recurrence. The management
of individual tumors for which partial gastrectomy may be indicated is discussed in detail
elsewhere and includes:
● Adenocarcinoma. (See "Early gastric cancer: Treatment, natural history, and prognosis"
and "Surgical management of invasive gastric cancer".)
● Gastrointestinal stromal tumors. (See "Local treatment for gastrointestinal stromal tumors,
leiomyomas, and leiomyosarcomas of the gastrointestinal tract".)
● Neuroendocrine tumors. (See "Staging, treatment, and post-treatment surveillance of non-

metastatic, well-differentiated gastrointestinal tract neuroendocrine (carcinoid) tumors"
and "Multiple endocrine neoplasia type 1: Treatment" and "Management and prognosis of
the Zollinger-Ellison syndrome (gastrinoma)".)
● Lymphoma – Surgery does not play a role in the primary treatment of most patients with
gastric MALT or non-MALT (diffuse large B cell) lymphomas, except to manage gastric
perforation or bleeding not amenable to endoscopic management [7-9]. (See "Treatment
of extranodal marginal zone lymphoma of mucosa associated lymphoid tissue (MALT
lymphoma)".)
Benign tumors — Leiomyoma is the most common benign tumor for which partial gastric
resection is performed [10]. Partial gastric resection has also been described in the diagnosis
and/or treatment of less common submucosal lesions, including lipoma/adenomyoma and
juvenile polyposis [11,12]. (See "Local treatment for gastrointestinal stromal tumors,
leiomyomas, and leiomyosarcomas of the gastrointestinal tract".)
Ulcer disease — Antrectomy/distal gastrectomy may be required to manage ulcer disease but

is a treatment of last resort only after conservative management, including eradication of
Helicobacter pylori, has failed. Partial gastrectomy may also be indicated to manage
complications of ulcer disease (eg, gastric outlet obstruction, bleeding, perforation), or if there
is a suspicion of adenocarcinoma. (See "Surgical management of peptic ulcer disease".)
Antrectomy/distal gastrectomy may also be necessary to remove the source of

hypergastrinemia in selected patients with Zollinger-Ellison syndrome or in those with type I
(not associated with multiple endocrine neoplasia [MEN]) or type II (associated with MEN-1)
gastric carcinoid, with the extent of resection determined by the size and number of lesions.
Patients with type III gastric (sporadic) carcinoid may require antrectomy/distal gastrectomy or
total gastrectomy with extended lymph node dissection. (See "Management and prognosis of
the Zollinger-Ellison syndrome (gastrinoma)" and "Staging, treatment, and post-treatment
surveillance of non-metastatic, well-differentiated gastrointestinal tract neuroendocrine
(carcinoid) tumors".)
Morbid obesity — Partial gastric resection, in the form of sleeve gastrectomy, has been used in
the management of morbid obesity. The indications for bariatric surgery, sleeve resection, and
other bariatric surgical procedures are discussed elsewhere. (See "Bariatric operations for
management of obesity: Indications and preoperative preparation".)
Trauma — Partial gastric resection may be necessary to manage significant injuries to the

stomach. Because the stomach is well vascularized, resection is typically limited to the removal
of devitalized tissue. (See "Traumatic gastrointestinal injury in the adult patient".)
CONTRAINDICATIONS
Contraindications to abdominal surgery, in general, include systemic comorbidities that

preclude safe administration of anesthesia. (See 'Medical risk assessment' below.)
Antrectomy for ulcer disease should not be performed if pyloric inflammation prevents safe
dissection and preservation of surrounding structures (eg, portal triad, pancreas). Surgical
bypass in the form of a gastroenterostomy may be a better option. Patients with recurrent,
severe, and/or unusual disease (significant duodenal ulceration) should be screened for
gastrinoma prior to surgical intervention [13].
Contraindications for patients with malignant disease — The ability to offer partial

gastrectomy for malignant disease will depend upon the type of tumor, the extent of local
disease and the ability to achieve appropriate surgical margins, and the presence of metastatic
disease.
● Most surgeons would treat proximally placed malignant adenocarcinoma of the stomach
with a total gastrectomy rather than a proximal subtotal gastrectomy. (See 'Optimal
surgical margin' below and "Total gastrectomy and gastrointestinal reconstruction".)
● An important contraindication to partial gastrectomy is presumed or proven hereditary

diffuse gastric cancer [14,15]. Total gastrectomy with intraoperative mucosal assessment
to ensure negative proximal and distal margins is a more appropriate treatment for the
majority of patients. (See "Hereditary diffuse gastric cancer" and "Total gastrectomy and
● For incurable advanced gastric cancer, chemotherapy is the standard of care. In a

randomized trial, gastrectomy followed by chemotherapy did not show any survival benefit
compared with chemotherapy alone [16]. Thus, gastrectomy cannot be justified in patients
with metastatic adenocarcinoma of the stomach unless complications such as obstruction,
bleeding, or perforation cannot be managed using other means. Obstruction can
selectively be managed by gastroenteric bypass rather than resection in the setting of an
advanced, locally aggressive tumor. Bleeding can be managed in select cases by external
beam radiation rather than surgery. (See "Local palliation for advanced gastric cancer".)
● Many patients with advanced gastric adenocarcinoma may be candidates for neoadjuvant
chemotherapy prior to consideration for gastric resection [17-20]. The British Medical
Research Council Adjuvant Gastric Cancer Infusional Chemotherapy (MAGIC) trial
evaluated a neoadjuvant regimen (ECF: epirubicin, cisplatin, fluorouracil) for T2 through T4
and/or node-positive gastric adenocarcinoma [20]. It found that ECF significantly improved
five-year survival over surgery alone (35 versus 23 percent, hazard ratio 0.75, 95% CI 0.6-
0.93). A German multi-institution trial has shown that the perioperative use of fluorouracil
with leucovorin, oxaliplatin, and docetaxel (FLOT) is markedly superior to ECF and thus
established a new standard for systemic therapy [21]. (See "Surgical management of
invasive gastric cancer", section on 'Adjuvant and neoadjuvant therapy' and "Adjuvant and
neoadjuvant treatment of gastric cancer".)
● Patients with metastatic gastrointestinal stromal tumors (GISTs) should be managed by a

multidisciplinary team, including surgery and medical oncology. Resection should be
reserved for patients with complications or those showing minimal response of
symptomatic primary tumor to targeted therapies such as imatinib. (See "Adjuvant and
neoadjuvant imatinib for gastrointestinal stromal tumors".)
TUMOR STAGING
Patients undergoing partial gastric resection for malignancy should undergo preoperative
staging to the extent that is possible ( table 2), including computed tomography (CT) of the
abdomen, or endoscopic ultrasound, to evaluate the extent of locoregional disease and the
presence of metastatic disease, which may contraindicate the resection. (See "Clinical features,
diagnosis, and staging of gastric cancer" and "Surgical management of invasive gastric cancer",
section on 'Staging evaluation'.)
Staging laparoscopy may be indicated for patients with gastric adenocarcinoma; however, the
selection of patients who need staging laparoscopy is controversial. An expert international
multidisciplinary panel felt that the usefulness of staging laparoscopy was indeterminate,
although some evidence-based guidelines do encourage at least selective use of the procedure
[22-24]. Whether staging laparoscopy should be a separate procedure or concurrent at the time
of the planned resection has not been evaluated, although in our institution we are increasingly
favoring performing laparoscopy prior to initiation of systemic treatment as FLOT (fluorouracil
with leucovorin, oxaliplatin, and docetaxel) chemotherapy would not be recommended in the
metastatic setting. There is no formal role for staging laparoscopy for other malignant tumors
of the stomach. The indications for staging laparoscopy and general procedural details for
performing staging laparoscopy for digestive malignancies are discussed elsewhere. (See
"Surgical management of invasive gastric cancer", section on 'Staging laparoscopy' and "Clinical
features, diagnosis, and staging of gastric cancer", section on 'Staging laparoscopy' and
"Diagnostic staging laparoscopy: General principles for staging primary digestive
malignancies".)
PREOPERATIVE PREPARATION
Medical risk assessment — The preoperative assessment prior to gastric resection should

identify the presence of medical comorbidities. The majority of gastric resections are performed
under elective circumstances for which there is adequate time for risk assessment and
optimization of the patient's medical status. Preoperative medical assessment is discussed
elsewhere. (See "Evaluation of cardiac risk prior to noncardiac surgery" and "Evaluation of
preoperative pulmonary risk" and "Preoperative medical evaluation of the healthy adult
patient".)
Data from the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database
from 1992 to 2002 indicated that 60 percent of patients undergoing surgery for gastric cancer
were over 75 years, and approximately 70 percent had more than two associated medical
comorbidities [25].
Antibiotic prophylaxis — Antibiotic prophylaxis is recommended for procedures that enter into

the lumen of the gastrointestinal tract. (See "Antimicrobial prophylaxis for prevention of surgical
site infection following gastrointestinal procedures in adults", section on 'Gastroduodenal
procedures' and "Antimicrobial prophylaxis for prevention of surgical site infection in adults",
section on 'Antibiotic administration'.)
Appropriate antibiotic choices are given in the table ( table 3). We use antibiotics directed
against skin and colonic flora. Although there is no direct evidence to support this practice, the
recognized risk of potential colon injury, or the need to resect the colon en bloc when managing
gastric tumors, particularly advanced tumors, may justify antibiotic prophylaxis as with elective
colon resection [26,27]. (See "Antimicrobial prophylaxis for prevention of surgical site infection
following gastrointestinal procedures in adults".)
Thromboprophylaxis — Thromboprophylaxis should be administered according the patient's

risk for thromboembolism ( table 4). Patients undergoing partial gastrectomy for malignancy
are at moderate-to-high risk for thromboembolism, and pharmacologic prophylaxis is
recommended. For all patients, we use intermittent pneumatic compression, which should be
placed prior to induction of anesthesia and continued until the patient is ambulatory. The
indications and specific therapeutic choices for preventing thromboembolism in surgery
patients are discussed in detail elsewhere. (See "Prevention of venous thromboembolic disease
in adult nonorthopedic surgical patients".)
Informed consent — In addition to the risks associated with surgery, in general, and the risks
of anesthesia, patients should be made aware of the potential for acute perioperative (eg,
anastomotic leak, duodenal stump leak) and long-term complications (eg, anastomotic stricture,
marginal ulcer, bowel obstruction) related to the procedure [28]. In addition, patients should be
counseled about postgastrectomy syndromes, which are due to alterations in gastric anatomy
and physiology. (See "Postgastrectomy complications".)
Patients undergoing partial resection for peptic ulcer disease, although rare, should also be
made aware of the need for lifetime surveillance of the gastric remnant for the development of
cancer, which can occur roughly 15 years or more after partial gastrectomy [29].
GENERAL CONSIDERATIONS
Partial gastrectomy is performed under general anesthesia. For patients undergoing upper
abdominal surgery, non-narcotic thoracic epidural anesthesia may simplify postoperative pain
management and allow early postoperative mobilization, which may expedite the return of
gastrointestinal function [30,31]. (See "Epidural and combined spinal-epidural anesthesia:
Techniques".)
Open versus laparoscopic partial gastrectomy — The choice between an open surgical versus
laparoscopic approach to partial gastric resection depends upon the indication for surgery, the
experience of the operator, and the preferences of the surgeon and patient. As with most
procedures performed laparoscopically, the operating surgeon should have sufficient

experience with the open procedure and should be able to perform a comparable anatomic
dissection and reconstruction using laparoscopic techniques, particularly when managing
malignancies.
Laparoscopic partial gastrectomy has been described for many indications [10,32-40]. The
available data suggest that, compared with open gastrectomy, laparoscopic gastrectomy takes
significantly longer to perform, but with increasing operator experience, operating times have
decreased [37,41]. In systematic reviews, laparoscopic surgery is associated with quicker return
of gastrointestinal function, faster ambulation, shorter hospital stay, and comparable
complication and tumor recurrence rates [35,38,42]. However, most individual studies have
been small and are likely not adequately powered to detect differences in important clinical
outcomes.
A laparoscopic approach may be most feasible for limited gastric resections that require
minimal dissection, such as with wedge sleeve resection for benign indications [10,37]; however,
the laparoscopic approach has also been used for resecting malignant gastric tumors [33-
35,38]. A systematic review identified one randomized trial and six observational studies
comparing open and laparoscopic surgery for resectable gastric cancer [38]. The results of
these studies were combined to evaluate the outcomes of 178 patients undergoing
laparoscopic gastrectomy and 278 undergoing open gastrectomy. Laparoscopic gastrectomy
took significantly longer to perform compared with open gastrectomy (weighted mean
difference [WMD] 44 minutes, 95% CI 20-69) but was associated with less blood loss (WMD 122
cc, 95% CI 208 to -37) and shorter hospital stay (WMD -6.2 days, 95% CI 9.4 to -2.8). There were
no significant differences between the laparoscopic and open groups concerning the number of
lymph nodes resected, or for cancer-related mortality (adjusted to five years).
Laparoscopic gastrectomy for cancer is discussed in detail elsewhere. (See "Laparoscopic

gastrectomy for cancer".)
Incision and exposure — The patient should be positioned supine. For open gastrectomy, a
midline abdominal approach is typically used. A self-retaining retractor helps to retract the liver
and intestinal contents, facilitating exposure. (See "Incisions for open abdominal surgery",
section on 'Midline incision'.)
For a laparoscopic approach, the abdominal cavity is accessed and insufflated, and multiple
ports are placed under direct vision ( figure 6). Placing the patient in reverse Trendelenburg
position moves the intestinal contents away from the upper abdomen. General issues related to
laparoscopic access are discussed in detail elsewhere. (See "Abdominal access techniques used
in laparoscopic surgery".)
Prior to initiating the dissection (open or laparoscopic), the abdominal cavity, including the
peritoneal surfaces, should be thoroughly explored to evaluate for any metastatic disease. The
extent of locoregional disease should also be assessed.
Extent of resection
Optimal surgical margin — For patients undergoing potentially curative surgery for gastric
malignancy, a tumor-free resection margin (R0) on pathologic examination is the goal of
resection. The effect of margin status on prognosis is discussed in detail elsewhere. (See
"Surgical management of invasive gastric cancer", section on 'Prognosis'.)
Because of a propensity for intramural spread, a margin of resection around the tumor is
needed to ensure complete excision of gastric adenocarcinoma. The optimal margin of
resection has not been well studied and remains debated. Generally accepted margins are >2 to
3 cm for early gastric cancer and >4 to 6 cm for advanced gastric cancer [43,44]. A review of 465
patients undergoing distal gastrectomy for gastric adenocarcinoma found improved overall
survival time for a proximal margin of 3.5 to 5.0 cm compared with a margin ≤3.0 cm (48 versus
23 months) [45]. For stage I disease, overall survival was similar for a 3.1 to 5.0 cm proximal
margin as a >5.0 cm margin. For stage II to III disease, overall survival was influenced by T stage
and nodal involvement, rather than margin.
However, even when the measured margin during postoperative pathologic examination is less
than these values, patient survival may not be impacted [46]; distant failures predominate even
in patients with positive surgical margins. (See "Surgical management of invasive gastric
cancer", section on 'Sites of disease recurrence'.)
To identify whether the intraoperative margin is adequate, intraoperative frozen sections of the
proximal and distal margins should be obtained in all patients undergoing potentially curative
surgery. Based upon the results of these frozen sections, a wider excision may be necessary.
However, experts in this area recognize that it may be very difficult to obtain a negative margin
even with successive frozen sections [47]. Nevertheless, re-excision of a positive margin does
improve the prognosis of some patients with gastric cancer [48].
Margins for lymphoma and gastrointestinal stromal tumors (GISTs) need not be as extensive (1
to 2 cm), although there is no agreement on specific size of adequate margins. The use of
intraoperative frozen section for these lesions is not well described.
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Lymph node dissection — The Japanese classification defines the level of lymph node
dissection ( table 1) by the stations of lymph nodes removed ( figure 5) [4]. We find it more
practical to use a broader classification that defines the extent of lymph node dissection
according to the relationship of the nodes to the segment of stomach to be removed, as follows
[10]:
● D0 – Refers to an incomplete D1 lymph node dissection or no formal lymph node

dissection.
● D1 – Removal of lymph node basins directly related to the segment of stomach removed.
● D2 – Removal of lymph node basins directly related to the segment of stomach removed
AND lymph node basins along major named neurovascular arcades supplying that region
of the stomach.
● D3 – Removal of lymph node basins directly related to the segment of stomach removed
AND lymph node basins along major named neurovascular arcades supplying that region
of the stomach AND para-aortic lymphadenectomy.
The extent of lymph node dissection needed during gastric resection for gastric
adenocarcinoma is somewhat controversial. Treatment guidelines published by the National
Comprehensive Cancer Network, CancerCare Ontario, and the European Society of Surgical
Oncology recommend that D2 lymph node dissection is preferred over a D1 dissection [23,24].
However, Japanese surgeons routinely perform extended lymphadenectomy (D2 or D3) [49].
However, in view of the higher reported rates of operative mortality in randomized trials when
more extensive dissection is performed, this recommendation should be tempered by where
and by whom the operation is being performed. The issues surrounding this controversy are
discussed in detail elsewhere. (See "Surgical management of invasive gastric cancer", section on
'Extent of lymph node dissection'.)
Sentinel lymph node dissection may become useful for patients with early gastric cancer
[50,51]. However, technical issues need to be resolved before sentinel lymph node dissection is
accurate enough to be routinely applied; the false negative rate has been unexpectedly high
[52]. A systematic review identified 26 observational studies using sentinel lymph node
detection using various methods, including colored dye, radiocolloid, and dye plus radiocolloid
[53]. The false negative rate was 13 percent with dye plus radioactive colloid, 18.5 percent with
radiocolloid alone, and 35 percent with dye alone. Other issues, such as the optimal type of
tracer, site of injection, manner of detection and harvesting, and learning curve, all need to be
resolved [51].
For patients with GIST tumors, no effort is made to perform an extended lymph node
dissection, because lymph node involvement is rare. For patients with neuroendocrine tumors,
the extent of the lymph node dissection will depend on the type of gastric neuroendocrine
tumor. (See "Staging, treatment, and post-treatment surveillance of non-metastatic, well-
differentiated gastrointestinal tract neuroendocrine (carcinoid) tumors", section on 'Stomach'.)
RESECTION TECHNIQUES
The type and extent of gastric resection is determined by the location, nature, and extent of
disease. Each technique has defined indications and specific, although sometimes overlapping,
reconstructive options.
The options for partial gastric resection are listed. Each of these techniques is briefly reviewed
below.
● Local excision/wedge resection
• Benign tumor excision
• Traumatic injury to the stomach
• Gastrointestinal stromal tumors (GISTs) amenable to wedge resection with appropriate

1 to 2 cm gross margins
● Sleeve (tube) gastrectomy
• Management of morbid obesity
● Proximal subtotal gastrectomy
• Malignant tumor of the proximal (upper one-third) of the stomach
• Traumatic injury
● Antrectomy/distal gastrectomy/pylorus preserving segmental gastrectomy
• Malignant tumor in the distal (lower two-thirds) of the stomach
• Refractory peptic ulcer disease or ulcer disease associated with neuroendocrine tumors
• Traumatic injury
Local excision/wedge resection — The goal of wedge resection is to obtain an appropriate

margin without significant narrowing of the stomach. Care must be taken near the
gastroesophageal junction or the pylorus to avoid this problem. To perform local
excision/wedge resection, the area of interest is identified and a gastrointestinal stapler can be
fired once across the stomach margin or twice to remove a triangular wedge of gastric tissue.
Sleeve gastrectomy — Sleeve gastrectomy is a type of partial gastrectomy in which the

majority of the greater curvature of the stomach is removed using gastric staplers, creating a
tubular stomach. It is used almost exclusively as a bariatric procedure. (See "Laparoscopic
sleeve gastrectomy".)
Antrectomy/distal subtotal gastrectomy — Antrectomy is used to treat patients with

refractory peptic ulcer disease, neuroendocrine tumors, or gastric adenocarcinoma. When
performed for distal (lower two-thirds) gastric adenocarcinoma, antrectomy/distal gastrectomy
includes resection of associated lymph node basins for adenocarcinoma.
To perform antrectomy/distal subtotal gastrectomy ( figure 7):
● Identify the proximal resection margin. The incisura is generally recognized as the
proximal extent of resection in an antrectomy. However, if needed, carry the proximal
dissection superior to the confluence of the gastroepiploic vessels to obtain a sufficient
margin.
● Mobilize the greater omentum ( figure 3) from the transverse colon to remove it with the
specimen for tumor resection. The extent of omentectomy is determined by the proximal
extent of the gastric resection. The omentum can be left in situ in the case of antrectomy
for benign disease.
● Identify the pylorus. Ligate and divide the right gastric and gastroepiploic vessels at the
pylorus.
● Skeletonize and transect the duodenum just distal to the pylorus using a linear stapler.
Care should be taken to avoid injury to the structures of the portal triad.
● Oversew the duodenal stump using a running, permanent suture (eg, 3-0 Prolene) on a
noncutting needle.
● Carry the dissection cephalad along the greater and lesser curves of the stomach. For
adenocarcinoma, the lesser omentum (gastrohepatic ligament) should be harvested with
the specimen provided there is not a variant hepatic artery ( figure 8) coursing through
this region. For patients with benign disease, harvest the greater curve of the stomach just
outside the gastroepiploic arcade.
● For a subtotal gastrectomy, the distal left gastroepiploic arcade and some of the short
gastric vessels will need to be ligated.
● Transect at the proximal stomach margin using a linear gastrointestinal stapler.
● For patients requiring a D2 nodal dissection, send the named nodal basins along the
vascular arcades of the stomach as separate, labeled specimens for pathologic
examination.
Function-preserving partial gastrectomy — Function-preserving techniques for partial

gastrectomy have been introduced by the Japanese as a means to limit or avoid syndromes that
result from altered anatomy and/or physiology following traditional methods of gastric
resection and reconstruction (ie, postgastrectomy syndromes) [54-57]. Function-preserving
techniques include those that preserve the pylorus (pylorus-preserving segmental gastrectomy)
[54-56], those that preserve the distal named branches of the vagus nerves [57], and operations
that create a pouch or "neo-stomach."
Pylorus-preserving segmental gastrectomy (PPSG) — Pylorus-preserving segmental

gastrectomy (PPSG), which resects a portion of the stomach but leaves the pylorus intact (
figure 9), was originally developed as a treatment approach for gastric ulcer surgery as a
means to improve quality of life and avoid postgastrectomy syndromes. This technique has
been championed for patients with early gastric cancer (EGC), which accounts for nearly 50
percent of patients presenting with gastric cancer in Japan [54-56]. Regardless of the status of
lymph node metastasis, five-year survival rates of 93 to 98 percent have been reported [54]. A
PPSG approach has not been described in the North American literature, likely because most
patients in North America present with more advanced disease.
In comparison with Billroth I distal gastrectomy, patients undergoing PPSG have fewer
subjective postprandial complaints and lower rates of symptomatic bile reflux and gallstone
formation [55]. There may also be an improved ability to maintain weight and a decrease in
symptoms of early dumping and reflux gastritis [56]. (See "Postgastrectomy complications".)
An important aspect of PPSG is the use of lymph node stations ( figure 5) as the landmarks for
the extent of resection more so than the anatomic landmarks used for the resections described
above. To perform pylorus-preserving segmental gastrectomy:
● Following omentectomy, harvest the lymph nodes along the right gastroepiploic vessels.
● Divide the right gastroepiploic arcade distal to the infrapyloric artery and carry the
dissection along the greater curve of the stomach.
● Harvest the left gastroepiploic vessels with the station 4sb lymph nodes.
● Harvest the lymph nodes of the lesser curve, and preserve the hepatic and pyloric
branches of the vagus nerves and right gastric vessels.
● Remove the distal stomach with stations 7, 8, 9, and 11p lymph nodes, preserving 3 cm of
antrum and the pylorus.
● Harvest the left gastric vessels and transect the stomach proximally with a 2 cm margin.
● Perform an end-to-end anastomosis of the proximal to distal gastric remnants using a full-
thickness single-layer suture (eg, Gambee suture ( figure 10)).
Preservation of the vagus nerves — Traditional resection techniques for gastric

adenocarcinoma have not emphasized preservation of the vagus nerves, but this practice is
supported by those who treat patients with early gastric cancer and can be performed in
conjunction with a D2 lymphadenectomy [54-57]. Preserving the hepatic branch of the anterior
vagus nerve and celiac branch of the posterior vagus nerve decreases the incidence of
postoperative diarrhea and of postgastrectomy gallstone formation [57]. (See "Vagotomy".)
Proximal subtotal gastrectomy — Proximal subtotal gastrectomy ( figure 11) may be an

option for tumors in the proximal (upper third) of the stomach that do not invade the
gastroesophageal junction. However, total gastrectomy ( figure 12) is the more often favored
procedure. (See "Surgical management of invasive gastric cancer" and "Total gastrectomy and
Tumors of the gastroesophageal junction are managed with esophagogastrectomy, which is

discussed elsewhere. (See "Surgical management of resectable esophageal and
esophagogastric junction cancers", section on 'Esophagogastric junction cancer resection'.)
GASTROINTESTINAL RECONSTRUCTION
Reconstructive procedures can be broadly thought of as those that preserve duodenal

continuity, those that preserve jejunal continuity, those that preserve both, and those that
incorporate some form of pouch reconstruction. Duodenal continuity is important for
preventing loss of fat-soluble vitamins, while jejunal continuity is important for preventing
retrograde flow of jejunal contents, which can occur because transection of the jejunum
interrupts the electrical activity normally initiated by the duodenal pacemaker, thus impairing
antegrade peristalsis [58].
Ideally, gastric reconstruction would avoid adverse consequences related to the loss of stomach
tissue and function (ie, postgastrectomy syndromes), but each type of reconstruction is
associated with, at a minimum, some degree of dumping (early or late) since the pylorus is
typically removed (except for pylorus-preserving segmental gastrectomy). The characteristics
and postgastrectomy syndromes associated with each of these reconstructions are given in the
table ( table 5). (See "Postgastrectomy complications".)
The most common gastric reconstructive procedures following partial (typically distal)
gastrectomy in North America are the Billroth I, Billroth II, and Roux-en-Y reconstructions.
Billroth I — The Billroth I reconstruction ( figure 13) preserves duodenal and jejunal
continuity by anastomosing the remnant stomach to the duodenal stump in a primary end-to-
end fashion. Billroth I reconstruction is the preferred method of reconstruction when the
proximal gastric remnant and the duodenal stump can be approximated without tension, which
is generally possible only after antrectomy.
The most common postgastrectomy syndrome ( table 5) associated with Billroth I

reconstruction is reflux of biliary contents retrograde into the stomach causing alkaline gastritis.
If the residual gastric remnant is small or nonfunctional, there will likely be some degree of
dumping. (See "Postgastrectomy complications".)
Billroth II — The Billroth II reconstruction ( figure 13) anastomoses the remnant stomach to
the proximal jejunum in an end-to-side fashion. This reconstruction preserves jejunal but not
duodenal continuity and is used when a Billroth I reconstruction is not possible, such as with
more extended distal gastrectomy (ie, more than the antrum is resected). The Billroth II
reconstruction has an afferent limb from the duodenum and an efferent limb extending distally.
For a Billroth II reconstruction, the jejunal anastomosis can be performed in an antecolic or
retrocolic, isoperistaltic, or antiperistaltic fashion ( figure 14). Functional differences between
these have not been documented [59].
Following Billroth II reconstruction, patients can expect to suffer from alkaline reflux gastritis
and some dumping ( table 5), but unlike Billroth I reconstruction, Billroth II also leads to some
degree of malabsorption, particularly of fat-soluble vitamins, because of loss of duodenal
continuity. (See "Postgastrectomy complications".)
Roux-en-Y gastrojejunostomy — Roux-en-Y reconstruction ( figure 7) diverts the bilious

drainage away from the gastric remnant. Although patients suffer from lesser degrees of reflux
than seen in Billroth reconstruction (I or II), patients report dumping to a greater or lesser
extent [60]. However, Roux-en-Y reconstruction may lead to gastric atony, and this, together
with the adverse effect of jejunal transection, contributes to a syndrome of abdominal pain and
vomiting, known as the "Roux syndrome" or "Roux stasis syndrome." Patients with severe Roux
stasis syndrome may require completion gastrectomy. (See "Postgastrectomy complications".)
Roux-en-Y gastrojejunostomy can be used in the same situations as a Billroth II, although it
does not preserve duodenal or jejunal continuity. The Roux-en-Y gastrojejunostomy
anastomoses the remnant stomach to an isoperistaltic roux limb of jejunum. The proximal
jejunum is anastomosed to the distal roux limb in an end-to-side fashion ( figure 11). The
optimal length of the afferent limb has received little attention. There is a balance between a
limb that is too short, which increases the risk of bile (alkaline) reflux gastritis, and one that is
too long, which may increase the risk of Roux stasis syndrome. In observational studies, the
appropriate length to minimize reflux and reduce the risk of Roux stasis syndrome appears to
be approximately 40 cm [60-62]. In one of these studies, the Roux limb was significantly longer
in patients with symptoms consistent with Roux stasis compared with those without stasis (41
versus 36 cm) [62]. Roux stasis was more common in women than men but equally common in
patients with and without vagotomy.
Choice of reconstruction — The choice of reconstruction following antrectomy for ulcer

disease or distal gastrectomy for tumor depends upon the remnant anatomy available for
reconstruction, taking into consideration the complications related to the specific
postgastrectomy physiology that will result. However, based upon randomized trials, Roux-en-Y
reconstruction appears to be tolerated better overall and leads to a better quality of life
compared with Billroth reconstruction (Billroth I or Billroth II). Whether to preferentially perform
a Roux-en-Y in patients whose anatomy supports a Billroth I or Billroth II, or convert to a Roux-
en-Y only if complications occur, remains controversial. For patients who have not undergone
vagotomy, we suggest a primary Roux-en-Y reconstruction. Patients who have had a vagotomy
have an increased risk of roux stasis syndrome. (See 'Roux-en-Y gastrojejunostomy' above.)
A meta-analysis of 15 randomized trials comparing at least two of the gastric reconstruction

techniques (ie, Billroth I, Billroth II, or Roux-en-Y reconstruction) following gastrectomy
assessed postoperative morbidity and mortality, quality of life, and the incidence of
postgastrectomy syndromes [63]. Although complication rates were similar, patients with a
Roux reconstruction had fewer complaints of reflux gastritis and better quality of life. A later
trial also confirmed this finding [64].
The longest follow-up comparing techniques was reported for a trial that has followed 75
patients treated for duodenal ulcer for 12 to 21 years [65]. Patients were randomly assigned to
Billroth II (n = 39) or Roux-en-Y (n = 36) reconstruction between 1984 and 1993. Patients who
received a Roux-en-Y reconstruction had overall better clinical outcomes with a significantly
lower incidence of reflux esophagitis (3 versus 33 percent), fewer abnormal findings on upper
endoscopy of the distal esophagus and esophagogastric junction (10 versus 82 percent), and a
lower incidence of Barrett's esophagus (3 versus 21 percent). The gastric remnant was also
normal in significantly more Roux-en-Y patients (100 versus 18 percent). There were no
differences between the groups in the incidence of H. pylori infection. It is interesting to note
that the Roux limb in these patients was arbitrarily chosen to be 60 cm. Although the authors
were concerned about the potential for the "Roux syndrome," it was not clinically apparent in
their series.
In a retrospective comparative study of 1300 distal gastrectomies performed for cancer, Billroth
I reconstruction was associated with the least amount of weight and nutritional loss at one-year
follow-up [66]. Compared with Billroth I, Billroth II was associated with decreased body mass
index and low protein and albumin, whereas Roux-en-Y was associated with decreased body
mass index and low cholesterol. Other factors varied between the groups in this study, including
use of open versus laparoscopic approach, extent of lymph node dissection, and final tumor
stage. Thus, the results may not purely be a reflection of surgical choice but a composite of
tumor, surgical, and patient factors.
POSTOPERATIVE CARE AND FOLLOW-UP
Enhanced recovery after surgery (ERAS), also known as fast-track protocols, has been used for
selected patients undergoing gastric surgery [67,68]. Patients with American Society of
Anesthesiology (ASA) grade >2 malnutrition are not candidates. The elements of a fast-track
protocol are reviewed elsewhere. (See "Enhanced recovery after colorectal surgery".)
For most patients, the nasogastric tube can be discontinued in the recovery room or on the first
day postoperatively. If a nasogastric tube becomes dislodged or has fallen out, it should not be
replaced unless that patient has symptoms. The practice of routine nasogastric decompression
is not recommended, in general, and the available data suggest that gastrointestinal
decompression may not be needed even for patients undergoing esophageal or gastric surgery.
(See "Inpatient placement and management of nasogastric and nasoenteric tubes in adults",
section on 'Indications'.)
A systematic review identified five randomized trials comparing routine nasogastric or

nasojejunal decompression (n = 361) to no decompression (n = 361) in patients undergoing
gastrectomy for cancer [69]. A meta-analysis of three of these trials (two partial gastrectomy,
one total gastrectomy) found that patients with no gastric decompression had a significantly
shorter time to oral diet (weighted mean difference [WMD] 0.43 days, 95% CI 0.23-0.62). Time to
flatus, anastomotic leakage, pulmonary complications, length of hospital stay, and morbidity
and mortality were similar in both groups. A later review that included seven trials also found a
significantly shorter time to oral diet (WMD 0.43 days, 95% CI 0.25-0.61) and a trend toward a
decreased risk for pulmonary complications (relative risk 1.30, 95% CI 1.00-1.68). Rates for
anastomotic leakage, morbidity, and mortality were similar between two groups [70].
Subsequent studies appear to support these results [71-74].
Some patients may have prolonged spasm or edema of the gastrojejunal or jejunojejunal
anastomoses leading to nausea and emesis. If the gastrointestinal decompression has been
discontinued, a nasogastric tube may need to be replaced.
When nasogastric replacement is needed following proximal subtotal gastrectomy, we prefer

placement under fluoroscopy to avoid any risk of disrupting the proximal anastomosis; for distal
gastrectomy, fluoroscopic imaging may not be necessary.
Perioperative nutritional support — Prior to gastric resection, patients can have poor oral
intake due to nausea, vomiting, or early satiety and may be malnourished, increasing the risk
for surgical complications. In addition, some patients may not be able to resume oral intake due
to spasm or edema of the gastrojejunal or jejunojejunal anastomoses [28]. In the setting of
preoperative malnutrition, perioperative nutritional support should be provided, which can be
initiated via total parenteral nutrition (TPN) or a feeding jejunostomy placed at the time of the
gastric resection [75].
If a feeding jejunostomy tube is to be used, it should be placed into the jejunum approximately
30 to 40 cm beyond the most distal anastomosis. The tube should be flushed twice daily for the
first 24 hours, and thereafter, it can be used to provide enteral support. Enteral feedings can be
initiated as a dilute solution at approximately 10 mL per hour and increased to the target rate.
There may be a role for preoperative nutritional support if the patient's nutritional indices are
severely depressed. (See "Overview of perioperative nutrition support", section on 'Preoperative
nutrition support'.)
Postgastrectomy diet — The extent of alteration of oral intake will be determined by the size of
the gastric remnant and the need to conservatively manage postgastrectomy syndromes. Small
frequent meals, high in protein and inclusive of fat, should be consumed approximately six
times per day. Liquids may need to be taken separately from solids. Meals high in simple
carbohydrates can contribute to dumping syndrome and may need to be avoided. The patient
should be followed closely, at least initially, by a dietician experienced with managing patients
who have undergone this procedure.
Vitamin and mineral supplementation may also be necessary:
● Patients who have undergone subtotal gastrectomy will need vitamin B12
supplementation. (See "Clinical manifestations and diagnosis of vitamin B12 and folate
deficiency".)
● Patients who have undergone reconstructive procedures that bypass the duodenum (eg,
Billroth II, Roux-en-Y) may require supplementation of fat-soluble vitamins. (See "Overview
of vitamin A" and "Overview of vitamin D" and "Overview of vitamin E" and "Overview of
vitamin K".)
● Calcium and iron should also be supplemented. (See "Treatment of iron deficiency anemia
in adults" and "Treatment of hypocalcemia".)
Follow-up — Following partial gastric resection, the patient should follow up to evaluate the
incision(s) and overall recovery, and periodically thereafter to monitor weight, nutritional status,
and the presence of any symptoms that may indicate the development of complications related
to the gastric resection or reconstruction. Symptoms may include weight loss, fever, abdominal
pain, early satiety, persistent vomiting, reflux symptoms, hematemesis, and/or unexplained
anemia. Further abdominal imaging or endoscopic evaluation may be needed. (See
"Postgastrectomy complications" and "Endoscopic retrograde cholangiopancreatography (ERCP)
after Billroth II reconstruction" and "ERCP in patients with Roux-en-Y anatomy".)
Following gastric resection for malignancy, scheduled follow-up is suggested to detect clinical
symptoms of recurrence, which occurs most commonly in the first two to three years. However,
it is important to note that most patients undergoing partial gastrectomy for adenocarcinoma
do not fail surgical treatment due to gastric mucosal recurrence but rather develop nodal
disease or distant metastases. These issues are discussed in detail elsewhere. (See "Surgical
management of invasive gastric cancer", section on 'Post-treatment surveillance'.)
POSTGASTRECTOMY COMPLICATIONS
Complications following partial gastrectomy can be anatomic, related to the extent of gastric
resection and the type of reconstruction, or physiologic, related to the loss of function in the
section of stomach removed ( table 5). Postgastrectomy complications are discussed in detail
in a separate topic. (See "Postgastrectomy complications".)
PERIOPERATIVE MORTALITY
Perioperative mortality following partial gastric resection is low, even among appropriately
selected candidates with malignant tumor. In series comparing open with laparoscopic gastric
resection, no significant differences have been found, and reported perioperative mortality
rates range from 1 percent to greater than 10 percent for patients of advanced age and with
medical comorbidities [10,32-39,76,77].
Well-designed studies evaluating longer-term outcomes have traditionally been difficult as

partial gastrectomy for benign disease has declined substantially over the last several decades
[78,79]. The long-term evaluation of patients undergoing resection for adenocarcinoma is
confounded by recurrent disease and overall high case fatality rate [46]. Disease-specific
outcomes are discussed in separate topic reviews. (See "Early gastric cancer: Treatment, natural
history, and prognosis".)
SUMMARY AND RECOMMENDATIONS
● The terms "partial gastrectomy" or "subtotal gastrectomy" are broad and encompass
essentially any procedure that does not remove the entire stomach. Partial gastrectomy
can be proximal or distal. Other types of gastrectomy include wedge resection,
mucosal/sleeve resection, and pylorus-preserving segmental gastrectomy. Partial gastric
resection is used to treat most cases of benign gastric disease for which resection is
indicated (eg, ulcer disease, benign tumor, traumatic injury); malignant gastric tumors,
such as adenocarcinoma, where sufficient margins can be achieved; and in selected cases
of gastrointestinal stromal tumor (GIST), some neuroendocrine tumors, and complications
related to treatment of lymphoma. (See 'Indications' above.)
● The extent of gastric resection and type of reconstruction chosen is determined by the
location, nature, and extent of disease and impacts the nature of perioperative and later
complications, particularly the development of postgastrectomy syndromes. Partial
gastrectomy procedures include wedge resection, antrectomy/distal gastrectomy, distal
subtotal gastrectomy, proximal subtotal gastrectomy, pylorus-preserving segmental
gastrectomy, and mucosal/sleeve resection. (See 'Resection techniques' above.)
● Partial gastrectomy may not be an appropriate choice if excessive inflammation,

particularly in the region of the pylorus, precludes safe dissection (benign or malignant
disease) or if the location or type of tumor indicates total gastrectomy or the need for
primary medical therapy. An important contraindication to partial gastrectomy is
presumed or proven hereditary diffuse gastric cancer; these patients should undergo total
gastrectomy. For patients with gastric adenocarcinoma, partial gastric resection is
contraindicated in the setting of metastatic disease when the patient is asymptomatic or if
the extent of local disease prevents adequate surgical resection margins. In the latter case,
total gastrectomy should be performed.
Patients with GISTs of the stomach with locally advanced tumors and/or metastatic disease
at presentation should be assessed to determine if neoadjuvant targeted therapy is
indicated. (See 'Contraindications for patients with malignant disease' above.)
● For all patients undergoing partial gastrectomy, antibiotic prophylaxis is recommended.

For patients undergoing partial gastric resection who may require en bloc resection of the
colon or are at risk for colon injury during resection, we suggest antibiotic prophylaxis
appropriate to colon surgery ( table 3), rather than another regimen (Grade 2C). (See
'Antibiotic prophylaxis' above and "Antimicrobial prophylaxis for prevention of surgical site
infection following gastrointestinal procedures in adults" and "Antimicrobial prophylaxis
for prevention of surgical site infection in adults".)
● Thromboprophylaxis should be administered according to the patient's risk for

thromboembolism ( table 4). For patients undergoing partial gastrectomy for
malignancy, we recommend pharmacologic prophylaxis over no prophylaxis (Grade 1B).
These patients are at moderate-to-high risk for thromboembolism. For all patients, we
suggest intermittent pneumatic compression (IPC), rather than no compression (Grade
2C). IPC devices should be placed prior to induction of anesthesia and continued until the
patient is ambulatory.
● Patients undergoing partial gastric resection for malignancy should undergo preoperative
staging, including computed tomography (CT) of the abdomen, or endoscopic ultrasound
to evaluate the extent of locoregional disease and the presence of metastatic disease,
which may contraindicate the resection. Staging laparoscopy may be indicated for some
patients with gastric adenocarcinoma, particularly if the tumor has adverse features. There
is no formal role for staging laparoscopy for other malignant tumors of the stomach. (See
'Tumor staging' above.)
● The choice between an open surgical versus laparoscopic approach to partial gastric
resection depends upon the indication, experience of the operator, and preferences of the
surgeon and patient. Perioperative outcomes may be improved with a laparoscopic
approach; however, long-term outcomes, particularly oncologic outcomes, have yet to be
determined. (See 'Open versus laparoscopic partial gastrectomy' above.)
● For patients undergoing partial gastrectomy for adenocarcinoma, we suggest a margin of

2 to 3 cm for early gastric cancer and 4 to 6 cm for advanced gastric cancer, rather than a
lesser amount (Grade 2C). For patients with adenocarcinoma undergoing potentially
curative surgery, we suggest intraoperative frozen sections of the proximal and distal
margins. Based upon the results of the frozen sections, a wider excision may be necessary.
Re-excision of a positive margin may improve the prognosis of some patients with gastric
cancer. (See 'Optimal surgical margin' above and "Surgical management of invasive gastric
cancer", section on 'Surgical treatment for localized disease' and "Surgical management of
invasive gastric cancer", section on 'Sites of disease recurrence'.)
● Function-preserving techniques for partial gastrectomy have been introduced by the

Japanese as a means to limit or avoid postgastrectomy syndromes. Function-preserving
operations may preserve the pylorus, which minimizes the risk of dumping syndrome;
preserve the vagus nerves, thereby improving gastrointestinal motility; or create a pouch
or "neo-stomach," which improves gastric capacity. (See 'Function-preserving partial
gastrectomy' above.)
● Following partial gastric resection, the patient should follow up to evaluate the incision(s)
and overall recovery, and periodically thereafter to monitor weight, nutritional status, and
the presence of any symptoms that may indicate the development of complications.
Further abdominal imaging or endoscopic evaluation may be needed. Following partial
gastrectomy for malignancy, scheduled follow-up is suggested to evaluate for recurrence.
(See 'Follow-up' above and "Surgical management of invasive gastric cancer", section on
'Post-treatment surveillance'.)
● Several reconstructions are used to restore gastrointestinal continuity following partial

gastrectomy. The most common are the Billroth I, Billroth II, and Roux-en-Y
reconstructions with the choice between these depending upon the remnant anatomy
available for reconstruction and the status of the vagus nerves. For patients who have not
undergone vagotomy, we suggest Roux-en-Y reconstruction over Billroth reconstruction
(Billroth I or Billroth II) (Grade 2B). (See 'Gastrointestinal reconstruction' above.)
● Complications following partial gastrectomy can be related to anatomic or physiologic

alterations. The most concerning postoperative complication is anastomotic leak. The
nature and severity of postgastrectomy syndromes depend upon the extent of gastric
resection and the type of gastric reconstruction ( table 5). (See 'Postgastrectomy
complications' above and "Postgastrectomy complications".)
ACKNOWLEDGMENT
The editorial staff at UpToDate would like to acknowledge Debrah Wirtzfeld, MD, MSc, FRCSC,
FACS, who contributed to an earlier version of this topic review.
Use of UpToDate is subject to the Subscription and License Agreement.
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Topic 15161 Version 14.0
GRAPHICS
Anatomy of the stomach
The relationship of the stomach to surrounding structures is depicted in the

figure. The arterial supply to the stomach is derived primarily from the celiac axis.
The celiac axis arises from the proximal abdominal aorta and typically branches
into the common hepatic, splenic, and left gastric arteries. The common hepatic
artery usually gives rise to the gastroduodenal artery (in approximately 75% of
people), which, in turn, branches off into the right gastroepiploic artery and the
anterior and posterior superior pancreaticoduodenal arteries, which supply the
pancreas. The right gastroepiploic artery joins with the left gastroepiploic artery,
which emanates from the splenic artery in 90% of patients. The right gastric
artery branches from the hepatic artery and anastomoses with the left gastric
artery along the lesser curvature of the stomach. Because of its highly redundant
blood supply, stomach ischemia is rare.
Graphic 56689 Version 6.0
Lesser sac - Sagittal section
This sagittal view figure depicts the relationship of the lesser sac with the
stomach, transverse mesocolon, head of the pancreas, transverse colon,
omentum, and mesentery of the small bowel.
Gastrocolic ligament and the lesser sac
Parts of the stomach
This drawing shows the parts of the anterior surface of the stomach. The body of
the stomach is separated from the pyloric part by an oblique line that extends from
the angular notch (incisura angularis) on the lesser curvature to the greater
curvature.
Lymph node stations gastric cancer
Station Lymph node location Associated vessel

1 Right paracardial region of stomach First branch of ascending left gastric artery
2 Left paracardial region of stomach Esophagogastric branch of left subphrenic

artery
3a Lesser curvature Left gastric artery
3b Lesser curvature 2nd branch and distal part of the right gastric
artery
4sa Left greater curvature Short gastrics
4sb Right greater curvature Left gastroepiploic artery
4d Right greater curvature 2nd branch and distal part of the right
gastroepiploic artery
5 Suprapyloric 1st branch and proximal part of the right

gastric artery
6 Infrapyloric 1st branch and proximal part of the right

gastroepiploic artery
7 Left gastric artery
8a Anteriosuperior Common hepatic artery
8b Posterior Common hepatic artery
9 Celiac artery
10 Splenic hilum Splenic artery distal to pancreatic tail and at

roots of short gastrics
11p Along margin of pancreas Proximal splenic artery from origin to halfway
from origin to pancreatic tail
11d Along margin of pancreas Distal splenic artery from halfway from origin
to pancreatic tail to end of pancreatic tail
12a Hepatoduodenal ligament Proper hepatic artery from confluence of the

right and left hepatic ducts and upper border
of the pancreas
12b Hepatoduodenal ligament Along bile duct caudal half the confluence of
the right and left hepatic ducts and upper
border of the pancreas
12p Hepatoduodenal ligament Along portal vein caudal half the confluence
of the right and left hepatic ducts and upper
border of the pancreas
13 Posterior surface of the head of the pancreas
14V Root of the mesentery Superior mesenteric vein
15 Colonic Middle colic vessels
16a1 Paraaortic in diaphragmatic hiatus
16a2 Paraaortic Upper margin of the origin of the celiac artery

and lower border of the left renal vein
16b1 Paraaortic Lower border of the left renal vein and upper
border of the origin of the inferior mesenteric
vein
16b2 Paraaortic Between the upper border of the origin of the

inferior mesenteric artery and the aortic
bifurcation
17 Anterior surface of the pancreatic head

beneath the pancreatic sheath
18 Along the inferior border of the pancreatic

body
19 Infradiaphragmatic Predominantly along the subphrenic artery
20 Paraesophageal in the diaphragmatic

esophageal hiatus
110 Paraesophageal in the lower thorax
111 Supradiaphragmatic, separate from the

esophagus
112 Posterior mediastinal, separate from the

esophagus and the esophageal hiatus
Reproduced from: Japanese Gastric Cancer Association. Japanese classification of gastric carcinoma: 3rd English edition. Gastric
cancer 2011 14:101. Copyright © 2011; with kind permission from Springer Science + Business Media B.V.
Lymph node drainage of the stomach
The lymph node drainage of the stomach is depicted in the figure. The labels
correspond to the lymph node stations as classified by the Japanese Gastric
Cancer Association.
Modified from: Japanese Gastric Cancer Association. Japanese classification of gastric carcinoma:
3rd English edition. Gastric cancer 2011 14:101.
Stomach cancer TNM staging AJCC UICC 8th edition
Primary tumor (T)

T category T criteria
TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
Tis Carcinoma in situ: Intraepithelial tumor without invasion of the lamina propria,
high-grade dysplasia
T1 Tumor invades the lamina propria, muscularis mucosae, or submucosa
T1a Tumor invades the lamina propria or muscularis mucosae
T1b Tumor invades the submucosa
T2 Tumor invades the muscularis propria*
T3 Tumor penetrates the subserosal connective tissue without invasion of the

visceral peritoneum or adjacent structures¶Δ
T4 Tumor invades the serosa (visceral peritoneum) or adjacent structures¶Δ
T4a Tumor invades the serosa (visceral peritoneum)
T4b Tumor invades adjacent structures/organs
* A tumor may penetrate the muscularis propria with extension into the gastrocolic or gastrohepatic
ligaments, or into the greater or lesser omentum, without perforation of the visceral peritoneum
covering these structures. In this case, the tumor is classified as T3. If there is perforation of the visceral
peritoneum covering the gastric ligaments or the omentum, the tumor should be classified as T4.
¶ The adjacent structures of the stomach include the spleen, transverse colon, liver, diaphragm,
pancreas, abdominal wall, adrenal gland, kidney, small intestine, and retroperitoneum.
Δ Intramural extension to the duodenum or esophagus is not considered invasion of an adjacent

structure, but is classified using the depth of the greatest invasion in any of these sites.
Regional lymph nodes (N)

N category N criteria
NX Regional lymph node(s) cannot be assessed
N0 No regional lymph node metastasis
N1 Metastases in 1 or 2 regional lymph nodes
N2 Metastases in 3 to 6 regional lymph nodes
N3 Metastases in 7 or more regional lymph nodes
N3a Metastases in 7 to 15 regional lymph nodes
N3b Metastases in 16 or more regional lymph nodes
Distant metastasis (M)

M category M criteria
M0 No distant metastasis
M1 Distant metastasis
Prognostic stage groups
Clinical (cTNM)
When T is... And N is... And M is... Then the stage group
is...
Tis N0 M0 0
T1 N0 M0 I
T2 N0 M0 I
T1 N1, N2, or N3 M0 IIA
T2 N1, N2, or N3 M0 IIA
T3 N0 M0 IIB
T4a N0 M0 IIB
T3 N1, N2, or N3 M0 III
T4a N1, N2, or N3 M0 III
T4b Any N M0 IVA
Any T Any N M1 IVB
Pathological (pTNM)
is...
Tis N0 M0 0
T1 N0 M0 IA
T1 N1 M0 IB
T2 N0 M0 IB
T1 N2 M0 IIA
T2 N1 M0 IIA
T3 N0 M0 IIA
T1 N3a M0 IIB
T2 N2 M0 IIB
T3 N1 M0 IIB
T4a N0 M0 IIB
T2 N3a M0 IIIA
T3 N2 M0 IIIA
T4a N1 M0 IIIA
T4a N2 M0 IIIA
T4b N0 M0 IIIA
T1 N3b M0 IIIB
T2 N3b M0 IIIB
T3 N3a M0 IIIB
T4a N3a M0 IIIB
T4b N1 M0 IIIB
T4b N2 M0 IIIB
T3 N3b M0 IIIC
T4a N3b M0 IIIC
T4b N3a M0 IIIC
T4b N3b M0 IIIC
Any T Any N M1 IV
Post-neoadjuvant therapy (ypTNM)
is...
T1 N0 M0 I
T2 N0 M0 I
T1 N1 M0 I
T3 N0 M0 II
T2 N1 M0 II
T1 N2 M0 II
T4a N0 M0 II
T3 N1 M0 II
T2 N2 M0 II
T1 N3 M0 II
T4a N1 M0 III
T3 N2 M0 III
T2 N3 M0 III
T4b N0 M0 III
T4b N1 M0 III
T4a N2 M0 III
T3 N3 M0 III
T4b N2 M0 III
T4b N3 M0 III
T4a N3 M0 III
Any T Any N M1 IV
TNM: tumor, node, metastasis; AJCC: American Joint Committee on Cancer; UICC: Union for International
Cancer Control.
Used with permission of the American College of Surgeons, Chicago, Illinois. The original source for this information is the AJCC
Cancer Staging Manual, Eighth Edition (2017) published by Springer International Publishing.
Antimicrobial prophylaxis for gastrointestinal surgery in adults
Nature of Common Recommended Usual adult Redose

operation pathogens antimicrobials dose* interval¶
Gastroduodenal surgery
Procedures Enteric gram- CefazolinΔ <120 kg: 2 g IV 4 hours

involving entry negative bacilli,
≥120 kg: 3 g IV
into lumen of gram-positive
gastrointestinal cocci
tract
Procedures not Enteric gram- High risk◊ only: <120 kg: 2 g IV 4 hours
involving entry negative bacilli, cefazolinΔ
≥120 kg: 3 g IV
into lumen of gram-positive
gastrointestinal cocci
tract (selective
vagotomy,
antireflux)
Biliary tract surgery (including pancreatic procedures)

Open procedure Enteric gram- CefazolinΔ¥ <120 kg: 2 g IV 4 hours
or laparoscopic negative bacilli, (preferred)
≥120 kg: 3 g IV
procedure (high enterococci,
risk)§ clostridia OR cefotetan 2 g IV 6 hours
OR cefoxitin 2 g IV 2 hours
OR ampicillin- 3 g IV 2 hours
sulbactam
Laparoscopic N/A None None None

procedure (low
risk)
Appendectomy‡
Enteric gram- CefazolinΔ For cefazolin: For cefazolin:
negative bacilli,
PLUS <120 kg: 2 g IV 4 hours
anaerobes,
metronidazole
enterococci ≥120 kg: 3 g IV For metronidazole:
(preferred)
For metronidazole: N/A
500 mg IV
OR cefoxitinΔ 2 g IV 2 hours
OR cefotetanΔ 2 g IV 6 hours
Small intestine surgery

Nonobstructed Enteric gram- CefazolinΔ <120 kg: 2 g IV 4 hours

negative bacilli,
≥120 kg: 3 g IV
gram-positive
cocci

CefazolinΔ For cefazolin: For cefazolin:
Obstructed Enteric gram-
PLUS <120 kg: 2 g IV 4 hours
negative bacilli,
metronidazole
anaerobes, ≥120 kg: 3 g IV For metronidazole:
(preferred)
enterococci For metronidazole: N/A
500 mg IV
Hernia repair
Aerobic gram- CefazolinΔ <120 kg: 2 g IV 4 hours

positive organisms
≥120 kg: 3 g IV
Colorectal surgery†
Enteric gram- Parenteral:

negative bacilli,
CefazolinΔ For cefazolin: For cefazolin:
anaerobes,
enterococci PLUS <120 kg: 2 g IV 4 hours
metronidazole
≥120 kg: 3 g IV For metronidazole:
(preferred)
For metronidazole: N/A
500 mg IV
OR ampicillin- 3 g IV (based on 2 hours

sulbactamΔ, ** combination)
Oral (used in conjunction with mechanical bowel preparation):
Neomycin PLUS ¶¶ ¶¶
erythromycin
base or
metronidazole
IV: intravenous.
* Parenteral prophylactic antimicrobials can be given as a single IV dose begun within 60 minutes before
the procedure. If vancomycin or a fluoroquinolone is used, the infusion should be started within 60 to
120 minutes before the initial incision to have adequate tissue levels at the time of incision and to
minimize the possibility of an infusion reaction close to the time of induction of anesthesia.
¶ For prolonged procedures (>3 hours) or those with major blood loss or in patients with extensive burns,
additional intraoperative doses should be given at intervals one to two times the half-life of the drug.
Δ For patients allergic to penicillins and cephalosporins, clindamycin (900 mg) or vancomycin (15 mg/kg
IV; not to exceed 2 g) with either gentamicin (5 mg/kg IV), ciprofloxacin (400 mg IV), levofloxacin (500 mg
IV), or aztreonam (2 g IV) is a reasonable alternative. Metronidazole (500 mg IV) plus an aminoglycoside
or fluoroquinolone are also acceptable alternative regimens, although metronidazole plus aztreonam
should not be used, since this regimen does not have aerobic gram-positive activity.
◊ Morbid obesity, gastrointestinal (GI) obstruction, decreased gastric acidity or GI motility, gastric
bleeding, malignancy or perforation, or immunosuppression.
§ Factors that indicate high risk may include age >70 years, pregnancy, acute cholecystitis,
nonfunctioning gall bladder, obstructive jaundice, common bile duct stones, immunosuppression.
¥ Cefotetan, cefoxitin, and ampicillin-sulbactam are reasonable alternatives.
‡ For a ruptured viscus, therapy is often continued for approximately five days.
† Use of ertapenem or other carbapenems not recommended due to concerns of resistance.
** Due to increasing resistance of Escherichia coli to fluoroquinolones and ampicillin-sulbactam, local

sensitivity profiles should be reviewed prior to use.
¶¶ In addition to mechanical bowel preparation, the following oral antibiotic regimen is administered:
neomycin (1 g) plus erythromycin base (1 g) OR neomycin (1 g) plus metronidazole (1 g). The oral regimen
should be given as three doses over approximately 10 hours the afternoon and evening before the
operation. Issues related to mechanical bowel preparation are discussed further separately; refer to the
UpToDate topic on overview of colon resection.
Data from:
1. Antimicrobial prophylaxis for surgery. Med Lett Drugs Ther 2016; 58:63.
2. Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Surg Infec
(Larchmt) 2013; 14:73.
Modified Caprini risk assessment model for VTE in general surgical patients
Risk score
1 point 2 points 3 points 5 points

Age 41 to 60 years Age 61 to 74 years Age ≥75 years Stroke (<1 month)
Minor surgery Arthroscopic surgery History of VTE Elective arthroplasty
BMI >25 kg/m2 Major open surgery (>45 Family history of VTE Hip, pelvis, or leg
minutes) fracture
Swollen legs Laparoscopic surgery Factor V Leiden Acute spinal cord injury
(>45 minutes) (<1 month)
Varicose veins Malignancy Prothrombin 20210A
Pregnancy or Confined to bed (>72 Lupus anticoagulant

postpartum hours)
History of unexplained Immobilizing plaster Anticardiolipin

or recurrent cast antibodies
spontaneous abortion
Oral contraceptives or Central venous access Elevated serum

hormone replacement homocysteine
Sepsis (<1 month) Heparin-induced

thrombocytopenia
Serious lung disease, Other congenital or

including pneumonia acquired thrombophilia
(<1 month)
Abnormal pulmonary
function
Acute myocardial
infarction
Congestive heart failure

(<1 month)
History of inflammatory
bowel disease
Medical patient at bed

rest
Interpretation
Surgical risk Score Estimated VTE risk in

category* the absence of
pharmacologic or
mechanical
prophylaxis (percent)
Very low (see text for 0 <0.5

definition)
Low 1 to 2 1.5
Moderate 3 to 4 3.0
High ≥5 6.0
VTE: venous thromboembolism; BMI: body mass index.
* This table is applicable only to general, abdominal-pelvic, bariatric, vascular, and plastic and
reconstructive surgery. See text for other types of surgery (eg, cancer surgery).
From: Gould MK, Garcia DA, Wren SM, et al. Prevention of VTE in nonorthopedic surgical patients: antithrombotic therapy and
prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practical guidelines. Chest 2012;
141:e227S. Copyright © 2012. Reproduced with permission from the American College of Chest Physicians.
Port placement for foregut surgery*
A Veress needle is placed in the upper abdomen to insufflate the peritoneal cavity.
A 5 mm port is placed through the Veress needle tract, and the laparoscope is
placed. Additional ports are placed under direct vision. The 5 mm port in the
subxiphoid region is used for a laparoscopic liver retractor. Right and left subcostal
ports (5 mm) are placed, and two additional ports are placed midway between
these subcostal ports and the umbilicus. One of the midabdominal ports is used to
pass the surgical stapler (12 mm) and/or special suturing instruments.
The surgeon stands on the patient's right side using the dissector and stapler
through the right-sided ports (shown in red). The assistant stands on the patient's
left side operating the laparoscope with their left hand through the 5 mm
midabdominal port site and provides countertraction for the surgeon through the
left subcostal port site (shown in blue). Alternatively, the patient can be placed in a
split leg (ie, lithotomy) position, and the surgeon can operate from a position
between the legs.
* Port placement and technique may vary among laparoscopic surgeons.
Partial gastrectomy and reconstruction
Distal (partial) gastrectomy is performed by removing the distal portion of the

stomach (shaded region between line 2 and line 4). Gastrointestinal continuity
can be restored using one of three techniques. The first (B), known as a Billroth I
reconstruction, anastomoses the stomach to the duodenal remnant. The
Billroth II reconstruction (C) brings up a loop of proximal jejunum to create an
end-to-side gastrojejunoctomy. Another option is a Roux-en-Y
gastrojejunostomy (D), in which the more distal jejunum is anastomosed to the
stomach in an end-to-side fashion.
Variations in hepatic arterial supply
Figures A through E illustrate the most common variations of

hepatic artery anatomy.
Pylorus Preserving Segmental Gastrectomy
Pylorus-preserving segmental gastrectomy (A) is a variation of distal

gastrectomy that removes the distal stomach but maintains the pyloric
sphincter (shaded region between line 2 and line 3). Gastrointestinal
continuity can be restored by anastomosing the remnant stomach
together in an end-to-end fashion.
Gambee suture
Proximal gastrectomy
Proximal gastrectomy removes the upper portion of the stomach (shaded region
in panel A between line 1 and line 2) and anastomoses the distal esophagus to a
loop of jejunum in an end-to-side fashion (esophagojejunostomy [EJ]).
Gastrointestinal continuity is then restored with either a jejunojejunostomy (JJ) in
the standard Roux-en-Y reconstruction (panel B) or with a gastrojejunostomy (GJ)
and a jejunojejunostomy (JJ) in the so-called "double-track" reconstruction (panel
C).
Total gastrectomy with reconstruction
Postgastrectomy syndromes
Preservation of
Type of gastric
gastrointestinal Dumping Malabsorption Alkaline reflux
reconstruction
continuity
Billroth I Duodenal, jejunal Yes No Yes
Billroth II Jejunal Yes Yes Yes
Roux-en-Y No Yes Yes No
Jejunal Duodenal Yes No No

interposition
Iliocecal Duodenal, jejunal No No Yes

interposition
Billroth reconstruction following gastrectomy
This illustration depicts the Billroth I and Billroth II methods of reconstruction

following vagotomy and antrectomy. The Billroth I consists of an end-to-end
gastrodoudenal anastomosis; in contrast, the Billroth II consists of an end-to-side
gastrojejunal anastomosis.
Modified from: Sedgwick CE. Gastrectomy. In: Atlas of Abdominal Surgery, Braasch JW, Sedgwick CE,
Veidenheimer MC, Ellis FH (Eds), WB Saunders Company, Philadelphia 1991. p.33.
Variations of Billroth II reconstruction
Modified from: Sedgwick, CE. Gastrectomy. In: Atlas of Abdominal Surgery, Braasch, JW,
Sedgwick, CE, Veidenheimer, MC, Ellis, FH (Eds), WB Saunders Company, Philadelphia 1991. p. 33.
Contributor Disclosures
Pamela Hebbard, MD, FRCS No relevant financial relationship(s) with ineligible companies to
disclose. David I Soybel, MD No relevant financial relationship(s) with ineligible companies to
disclose. Wenliang Chen, MD, PhD No relevant financial relationship(s) with ineligible companies to
disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must
conform to UpToDate standards of evidence.
Conflict of interest policy

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SURGICAL ANATOMY AND PHYSIOLOGY OF THE STOMACH

Lymphatic drainage — For patients with gastric cancer, lymphadenectomy is performed in

● Peripyloric – Refers to lymph nodes above and below the pylorus

● Peripancreatic – Refers to lymph nodes in the region of the pancreas

● Periaortic – Refers to lymph nodes in the vicinity of the aorta

Malignant tumors — Whether partial gastrectomy is appropriate for the management of

● Neuroendocrine tumors. (See "Staging, treatment, and post-treatment surveillance of non-

Ulcer disease — Antrectomy/distal gastrectomy may be required to manage ulcer disease but

Antrectomy/distal gastrectomy may also be necessary to remove the source of

Trauma — Partial gastric resection may be necessary to manage significant injuries to the

Contraindications to abdominal surgery, in general, include systemic comorbidities that

Contraindications for patients with malignant disease — The ability to offer partial

● An important contraindication to partial gastrectomy is presumed or proven hereditary

● For incurable advanced gastric cancer, chemotherapy is the standard of care. In a

● Patients with metastatic gastrointestinal stromal tumors (GISTs) should be managed by a

Medical risk assessment — The preoperative assessment prior to gastric resection should

Antibiotic prophylaxis — Antibiotic prophylaxis is recommended for procedures that enter into

Thromboprophylaxis — Thromboprophylaxis should be administered according the patient's

procedures performed laparoscopically, the operating surgeon should have sufficient

Laparoscopic gastrectomy for cancer is discussed in detail elsewhere. (See "Laparoscopic

● D0 – Refers to an incomplete D1 lymph node dissection or no formal lymph node

● Local excision/wedge resection

• Benign tumor excision

• Traumatic injury to the stomach

• Gastrointestinal stromal tumors (GISTs) amenable to wedge resection with appropriate

● Sleeve (tube) gastrectomy

• Management of morbid obesity

● Proximal subtotal gastrectomy

• Malignant tumor of the proximal (upper one-third) of the stomach

● Antrectomy/distal gastrectomy/pylorus preserving segmental gastrectomy

• Malignant tumor in the distal (lower two-thirds) of the stomach

Local excision/wedge resection — The goal of wedge resection is to obtain an appropriate

Sleeve gastrectomy — Sleeve gastrectomy is a type of partial gastrectomy in which the

Antrectomy/distal subtotal gastrectomy — Antrectomy is used to treat patients with

To perform antrectomy/distal subtotal gastrectomy ( figure 7):

● Transect at the proximal stomach margin using a linear gastrointestinal stapler.

Function-preserving partial gastrectomy — Function-preserving techniques for partial

Pylorus-preserving segmental gastrectomy (PPSG) — Pylorus-preserving segmental

Preservation of the vagus nerves — Traditional resection techniques for gastric

Proximal subtotal gastrectomy — Proximal subtotal gastrectomy ( figure 11) may be an

Tumors of the gastroesophageal junction are managed with esophagogastrectomy, which is

Reconstructive procedures can be broadly thought of as those that preserve duodenal

The most common postgastrectomy syndrome ( table 5) associated with Billroth I

Roux-en-Y gastrojejunostomy — Roux-en-Y reconstruction ( figure 7) diverts the bilious

Choice of reconstruction — The choice of reconstruction following antrectomy for ulcer

A meta-analysis of 15 randomized trials comparing at least two of the gastric reconstruction

POSTOPERATIVE CARE AND FOLLOW-UP

A systematic review identified five randomized trials comparing routine nasogastric or

When nasogastric replacement is needed following proximal subtotal gastrectomy, we prefer

Vitamin and mineral supplementation may also be necessary:

Well-designed studies evaluating longer-term outcomes have traditionally been difficult as

SUMMARY AND RECOMMENDATIONS

● Partial gastrectomy may not be an appropriate choice if excessive inflammation,

● For all patients undergoing partial gastrectomy, antibiotic prophylaxis is recommended.

● Thromboprophylaxis should be administered according to the patient's risk for

● For patients undergoing partial gastrectomy for adenocarcinoma, we suggest a margin of

● Function-preserving techniques for partial gastrectomy have been introduced by the

● Several reconstructions are used to restore gastrointestinal continuity following partial

● Complications following partial gastrectomy can be related to anatomic or physiologic

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1. Pach R, Orzel-Nowak A, Scully T. Ludwik Rydygier--contributor to modern surgery. Gastric