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Subtotal gastrectomy is indicated in the presence of malignancy; in the presence of gastric ulcer that persists despite 3 weeks of intensive medical therapy; and in the presence of anacidity, pernicious anemia, suspicious cells by gastric cytology, or equivocal evidence for and against malignancy by repeated barium studies or fiberoptic gastroscopic observation with direct biopsy. It is most commonly utilized to control the acid factor in cases of intractable duodenal ulcer. A more conservative procedure should be considered in underweight patients with duodenal ulcer, especially females. Likewise, block excision of a gastric ulcer with multicentric frozen section studies should be made for proof of malignancy before performing a radical resection on the assumption the lesion may be malignant. This special effort for proof is especially important in all females as well as in underweight males.
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The preoperative preparation will be determined largely by the type of lesion presented and by the complication it produces. After surgery has been definitely planned, the patient without pyloric obstruction is encouraged to substitute a high-protein, high-carbohydrate, and high-vitamin diet for the rigid regimen so as to prepare for the postoperative period of limited caloric intake. Sufficient time should be taken to improve the nutrition if possible, especially if there has been considerable weight loss in a patient with obstruction. The fluid and electrolyte balance must be established by the intravenous injection of Ringer's lactate solution. Potassium deficiencies are corrected. Anemia and hypoproteinemia should be corrected as nearly as possible by transfusion of whole blood and plasma or by TPN. The increased incidence of pulmonary complications associated with upper abdominal surgery makes it imperative that elective gastric surgery be carried out only in the absence of respiratory infection, and active pulmonary physiotherapy with possible bronchodilators, expectorants, and positive pressure breathing exercises should be started in patients with chronic lung disease.
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If there is any degree of pyloric obstruction, the electrolyte balance, which includes potassium and sodium chloride; blood urea nitrogen levels; blood pH; and PCO2 or carbon dioxide combining power, must be returned to normal by the appropriate replacement therapy. Repeated gastric lavage, including several days of constant gastric suction, may be indicated until a satisfactory balance is attained. Constant gastric suction by means of a Levin tube is instituted before operation and maintained during and after operation unless ...