Chapter 6. Operative Management of Gastric Lesions

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

Absolute

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

Relative

• High operative risk because of age or comorbidities.

• 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.

Expected Benefits

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

Potential Risks

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

• 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.

• 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.

• 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.

Overview and Surgical Anatomy

• 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 ...