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  • Malignant tumors.
  • Benign tumors.
  • Intractable bleeding.
  • Chronic ulceration and inflammation.

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Absolute

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  • Inability to completely resect primary cancer.
  • Distant metastases.

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Relative

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  • High operative risk because of age or comorbidities.

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  • Operative mortality rates range from 3%–7%.
  • Resection of the spleen, pancreas, or colon may be required if a gastric tumor has invaded adjacent organs.

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Expected Benefits

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  • Surgical treatment of gastric malignancy with curative intent.
  • Resolution of bleeding or obstruction from benign or malignant gastric tumors or disease processes.

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Potential Risks

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  • Anastomotic leak.
  • Wound infection.
  • Pancreatic fistulae.
  • Intra-abdominal abscesses.

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  • A self-retaining retractor is necessary for optimal exposure.
  • Gastrointestinal anastomosis (GIA), thoracoabdominal (TA), and end-to-end anastomosis (EEA) staplers are often used for resection and reconstruction, and should be available.

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  • All patients should undergo fiberoptic endoscopy when neoplasm is suspected, and the diagnosis should be confirmed by multiple biopsies.
  • Preoperative tests should be performed to determine whether distant metastases are present.
    • Abdominal and pelvic CT scans, endoscopic ultrasound, or laparoscopy may be required for adequate staging.
  • A first- or second-generation cephalosporin is adequate as antibiotic prophylaxis for most gastric operations.
  • Deep venous thrombosis prophylaxis should be administered.
  • Bowel preparation is only useful in complicated cases when intestinal decompression is required and may serve to lessen the bacterial load if an intestinal resection is required.
  • Electrolyte and coagulation deficits should be corrected before operation.

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  • The patient should be supine, with the operating surgeon on the right side of the patient.
  • An upper midline incision is made from the xiphoid to the umbilicus to enter the abdomen.
    • Reverse Trendelenburg positioning facilitates exposure.
  • Once the abdomen has been entered, a routine exploration should be performed and a nasogastric tube placed by the anesthetist.

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Overview and Surgical Anatomy

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  • Figure 6–1A-C: Overview of surgical options for resection of gastric lesions.
    • For lesions involving the cardia of the stomach, esophagogastrectomy with esophagogastrostomy is performed (Figure 6–1A). A thoracotomy combined with laparotomy may be required. To ensure blood supply to the gastric remnant, the right gastroepiploic vessels are preserved.
    • For lesions in the body of the stomach, total gastrectomy with esophagojejunostomy is typically performed (Figure 6–1B).
    • For antral lesions, subtotal gastrectomy with gastrojejunal reconstruction is performed (Figure 6–1C).
  • Figure 6–2: Surgical anatomy of the stomach.
    • The esophagus terminates in the stomach after penetrating the diaphragm at the esophageal hiatus.
    • The stomach is divided into the fundus, body, and antrum based on differences in mucosal histology.
    • The fundus lies to the left and superior to the esophagogastric junction.
    • The junction of the body and antrum is approximately 6–8 cm proximal to the pylorus along the lesser curvature, to a point one-third the distance from the pylorus to the esophagogastric junction along the greater curvature.
    • Subtotal ...

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