Total Gastrectomy
Introduction
A laparoscopic total gastrectomy is a minimally invasive surgical procedure involving the complete removal of the stomach and any associated lymph nodes, together with a gastro-intestinal reconstruction to connect the remaining parts of the GI tract. It is typically performed as one of the main treatments for a variety of different gastric cancers.
The surgical procedure is performed under general anaesthetic and full recovery may take several weeks. During the recovery period, the patient is encouraged to keep active and maintain an adequate fluid and supplement intake. Postoperative pain can be managed using over the counter pain medication.
Complications of the procedure range from bleeding and surgical site infections to more severe complications such as anastomotic leaks and stricture formation.
What is it?
A total gastrectomy refers to the complete removal of the stomach. The stomach is a digestive organ which lies between the lower end of the oesophagus and the beginning of the small intestine, and in certain gastric cancers, a complete removal of the stomach may be necessary and offer the only chance of a cure. The procedure is formed laparoscopically (keyhole surgery) and hence is less invasive than the traditional open approach (1).
Why is it done?
A total gastrectomy is performed in the treatment of certain gastric tumours including:
- Gastric adenocarcinoma - Particularly where the gastric cancer is affecting the proximal stomach (upper portion of the stomach).
- Gastrointestinal stromal tumours - A partial gastrectomy may be considered here first (where only part of the stomach is removed), however a total gastrectomy may be necessary where this is not possible e.g. due to widespread metastasis.
- Hereditary diffuse gastric cancer - A total gastrectomy may be performed as prophylaxis in patients suffering from this condition.
- Signet ring carcinoma
It is important to note that even if you have confirmed gastric cancer, a gastrectomy may not be the first treatment option. In most cases, chemotherapy is first utilised, and surgery is considered if the cancer is refractory to this treatment. If you do not have any symptoms from your gastric cancer, it is unlikely that a complete removal of the stomach will be offered to you, as the surgery has only been shown to demonstrate benefit in patients suffering from severe and symptomatic disease (2).
Will I need to do any preparation?
Removal of the whole stomach is a major operation and has life-changing effects. As a result, it is important that the doctors conduct a variety of tests to ensure that the surgery is the best choice for you. Part of this process includes staging the tumour to assess the extent of spread of the cancer. This can include different methods:
1) Abdominal Imaging - A CT scan of your chest and abdomen is carried out prior to surgery to rule out any metastasis, as this may mean that a gastrectomy is not a suitable treatment option for you (5).
2) Esophagogastroduodenoscopy (OGD) - This is an endoscopic procedure that involves inserting a thin tube with a camera into your mouth and then down your oesophagus and into the stomach. This allows the surgeon to assess the location, size, and extent of spread of the tumour to plan for the best surgical approach. Endoscopy will also allow the surgeon to assess for any hiatus hernia, which could require additional steps in the surgery.
3) Colonoscopy - This is another endoscopic procedure which involves inserting a thin tube with a camera into your rectum and into your colon (large intestine). This is to check for any colorectal cancer which may have come from metastasis of the gastric cancer. This is particularly important in patients with hereditary diffuse gastric cancer (6).
4) Staging Laparoscopy - This procedure involves inserting a thin tube with a camera into your abdomen to allow the endoscopist and surgeon to visualise your abdominal structures and check for any metastatic disease. This is commonly conducted in those with gastric adenocarcinoma before the administration of chemotherapy.
Alongside this tumour staging process, you will also have a preoperative meeting with the surgeon and anaesthetist to go through any other medical conditions that you may have. This allows time to treat those medical conditions first, and to ensure that any medication you are currently taking is safe to continue in the period around your operation. You may be encouraged to temporarily stop taking certain anticoagulant medication such as warfarin and clopidogrel as these may increase the risk of intraoperative bleeding. You may also be given prophylactic antibiotics before the operation to reduce the risks of infection.
Technique
Anaesthesia
The procedure is formed under General Anaesthetic and typically lasts between 3-4 hours. On the day of your operation, you will meet the Anesthetist who will go through the procedure and discuss any concerns or questions you may have. Because general anaesthetic will be used, you will be unconscious throughout the surgery. As a result, an endotracheal tube will need to be placed down your throat to help you breathe (see diagram below).
What does it involve?
The surgery consists of three different portions:
- Removal of the stomach
- Removal of the associated lymph nodes
- Reconstruction of the stomach
Regarding removal of the stomach, the steps of the procedure are as follows:
1) Once the general anaesthetic has been administered, you will be placed in the Lloyd-Davis position (see below) which allows the surgeon the best exposure and view to conduct the operation. The surgeon will stand between your legs, with an assistant on each of your sides.
2) Once you have been placed in the appropriate position, the surgeon will begin to mark the sites for incisions. These incisions will allow the insertion of the various pieces of equipment, including the laparoscope which is a thin tube with a camera on the end, allowing the surgeon to see inside your abdomen. 5 incisions are usually made at various places on your abdomen.
3) At this stage of the procedure, the surgeon will begin the removal of the stomach with dissecting the left triangular ligament of the liver, which connects the left lobe of the liver to the diaphragm. A retractor is used to retract the left liver to give the surgeon a better view of the gastroesophageal junction.
4) The surgeon then removes the greater omentum (sheet of connective tissue) off the transverse colon and mesocolon. This allows the identification of the pylorus of the stomach (which connects to the duodenum of the small intestine) which is then marked with a suture.
5) The right gastric and right gastroepiploic vessels which supply the lesser curvature of the stomach are then ligated, followed by transection of the border between the pylorus of the stomach and the duodenum of the small intestine using a staples device. At this point, the surgeon takes special care not to damage any of the biliary of portal structures which supply the liver and gallbladder. Furthermore, the splenic artery is visualised and carefully protected to prevent any damage occurring to this, especially if lymph nodes around the splenic artery need to be removed.
6) Dissection along the lesser curvature of the stomach is continued by dividing the gastrohepatic ligament (ligament joining the liver to the stomach).
7) The left gastric vessels which supply the greater curvature of the stomach are then identified and divided, alongside a dissection of any associated structures which join to the greater curvature.
8) The distal end of the oesophagus is then transected using a stapler device. The end of the oesophagus will form an anastomosis with the jejunum in the gastric reconstruction operation. The surgeon will take care at this point to ensure that both the anterior and posterior vagus nerves are preserved, as damage to both of these nerves simultaneously can result in a lack of control over your bowels.
At this stage, the surgeon has completed the gastrectomy procedure, and the stomach can be removed in a bag through one of the incisions. The surgeon can now begin the process of gastric reconstruction in order to connect the distal end of the esophagus to the small intestine. This is usually conducted via a pouch formation using a Roux-en-Y procedure. The steps of the procedure are as follows:
1) The jejunum (middle portion of the small intestine) is transected distal to the ligament of Treitz. This loop of jejunum is then brought in front of the colon and up to the oesophagus.
2) The jejunum is then folded back onto itself, using sutures to hold it in place. This allows formation of the pouch that the food will pass down into on its way from the oesophagus into the bowels. A stapling device is used to create a join (anastomosis) between the two loops of jejunum, alongside creating an anastomosis between the pouch and the oesophagus. A further anastomosis is made from the most proximal section of the jejunum to the pouch (7).
At this stage, the gastric reconstruction has finished, and the whole procedure has come to an end. The surgeon will then remove the equipment, and insert gas into the abdomen to check the integrity of the anastomoses alongside inspecting for any bleeding in the operative field. All incision sites will be closed using sutures and the abdomen will be cleaned.
Post procedure course (follow up)
Once the surgery has been completed, you will be transferred to a recovery room where you will be woken up and your vital signs measured. You will also be fitted with a nasogastric tube, which is a thin tube placed down your nostril into your small intestine, to allow the removal of any bowel contents which may otherwise make you feel sick. A catheter will also be in place from when the surgery started to allow urine to drain and for the medical team to monitor your fluids.
Because a total gastrectomy is a major surgical procedure, it may take up to a week before you can begin eating a proper diet again. As a result, you will be given nutrition intravenously (into a vein) alongside a liquid diet for the first 24-48 hours, with progression to a soft diet once you feel ready. During your recovery at hospital, you will be required to take regular painkillers to help deal with the postoperative pain.
Between 3-5 days after the gastrectomy has been completed, you may be given a special x-ray which involves swallowing a contrast (gastrografin swallowing test). This enables the surgeon to check for any leaks in the anastomoses before a soft diet is commenced.
How long will I stay in hospital?
You can expect to stay in hospital for between 1-2 weeks before being discharged.
What care will I need at home?
On being discharged to home it is important that you maintain a carefully controlled diet. It may take several months to fully return to a regular diet, and hence you will be given advice from your doctors and a dietician on what to eat. While there are certain recommendations, each person may respond differently to various foods, and hence to prevent indigestion it is important to keep a note of the different foods that you eat and avoid the ones which make you feel bloated.
To begin with, you may be required to eat smaller, but more frequent meals. This is since the pouch and small intestine are restricted in size. Over several months, these begin to expand, and hence you can start to eat normal size portions again. It is also important to avoid high fibre foods such as rice, pasta, and oats, as these can make you feel full and bloated.
After a total gastrectomy, it is also common to lack insufficient intake of important vitamins and minerals such as iron, calcium, and vitamin C/D. Over time, malnutrition can result in conditions such as anaemia, scurvy, and muscle weaknesses. Hence it is important that you supplement your diet with these vitamins and minerals. Vitamin B12 is essential for normal functioning, and removal of the stomach means that this vitamin cannot be absorbed. Therefore, you will be required to have regular, usually monthly, injections of vitamin B12. In order to monitor your vitamins and minerals, you will be required to have regular blood tests at the request of your local GP (8).
It is important to incorporate gentle exercise into your routine to help with the healing process. This can include walking up the stairs, and going for light walks. However, you should avoid straining and stretching too much as this can cause large periods of discomfort.