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of the tumor (e.g., tail of pancreas, spleen). Hence,
selection of appropriate surgical procedure is determined
by location of the tumor, lymph nodal status, and
extragastric extension into the adjacent organs.
A total gastrectomy with esophagojejunostomy is
appropriate for proximal (upper third) gastric tumors. GE
junction tumors predominantly involving cardia (Siewert
type III—tumor lying within 2 to 5 cm distal to the “Z” line)
should be treated by an extended total gastrectomy with a
segment of esophagus for a safe margin. On the other
hand, GE junction tumors with predominant involvement of
the esophagus (Siewert type I—tumor lying within 1 to 5 cm
proximal to the “Z” line) should be treated by
transhiatal/transthoracic esophagectomy with proximal
gastrectomy and gastric pull-up with cervical/thoracic
esophagogastrostomy. The necessary extent of resection
for Siewert type II (tumor lying within 1 cm proximal or 2 cm
distal to the “Z” line) has been controversial and
intraoperative assessment of the tumor by an experienced
surgeon and frozen section of the resected margins help
decide the course—either a total gastrectomy or a
transhiatal esophagectomy. For tumors in the distal
stomach (lower two-thirds), a subtotal gastrectomy with
Bilroth II or Roux-en-Y reconstruction is appropriate
(Tables 1 and 2).
TABLE 1. Total Gastrectomy—Key Technical Steps
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TABLE 2. Total Gastrectomy—Potential Intraoperative Pitfalls
The extent of lymphadenectomy for gastric cancer
remains controversial. Western as well as Asian studies
could not show any survival benefit with D2 dissections
(lymph nodes along the named arteries of the stomach)
over D1 (immediate perigastric lymph nodes). Moreover,
few studies demonstrated increased morbidity and
mortality with extended lymph nodal dissections. Current
AJCC guidelines state that pathologic examination of at
least 15 lymph nodes is required for adequate staging
(Tables 3 and 4).
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TABLE 3. American Joint Committee on Cancer (AJCC) TNM Staging
Classification for Staging of the Stomach (7th ed., 2010)
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TABLE 4. American Joint Committee on Cancer (AJCC) TNM Staging
Classification for Staging of the Stomach (7th ed., 2010, Table 2)
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Used with the permission of the American Joint Committee on Cancer
(AJCC), Chicago, Illinois. The original source for this material is the
AJCC
Cancer Staging Manual
, 7th ed. (2010) published by Springer Science and
Business Media LLC, www.springer.com.
It is our preference and practice to perform gastrectomy
with D2 lymphadenectomy after neoadjuvant
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chemotherapy. Depending on the extent of tumor, a
splenectomy and/or a distal pancreatectomy is performed
to achieve negative margins (R0 resection). This strategy
maximizes the chances of R0 resection and provides
adequate number of lymph nodes for accurate staging of
the disease.
The patient in our case scenario had a moderately
differentiated adenocarcinoma of the stomach (Siewert
type III) with T3, N1, M0—stage IIB, that is, locally advanced
but was resectable. Hence, as a part of multimodality
treatment, he underwent neoadjuvant chemotherapy with
Etoposide, Cisplatin, and 5-FU. He then underwent a total
gastrectomy with Roux-en-Y esophagojejunostomy.
Operative procedure
The patient is placed in a supine
position with consideration given to the possibility of right
thoracic or cervical approach in case of GE junction tumors
needing esophagectomy. The skin from the chin to the
pubic symphysis is prepared and draped. We prefer a
midline incision extending from the xiphoid process to just
below the umbilicus for most patients undergoing a total
gastrectomy. A fixed retractor (e.g., Thomson) is used for
adequate exposure of the GE junction. Careful methodical
exploration of the abdomen is performed to exclude
metastasis, assess extent of resection, resectability, and
local extension to other viscera. The gastrohepatic
omentum is divided closer to the liver, closely watching for
accessory left hepatic artery, which should be preserved in
most cases. Dissection in the region of the esophagus and
the fundus of the stomach starts by taking a ring of
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diaphragmatic crura, dividing the phrenic vein en route and
taking the pericardial lymph node packet en bloc with the
specimen (Figure 1). The omentum and the lesser sac with
the lining are separated en bloc from the transverse colon.
The short gastric vessels along the greater curvature of the
stomach are divided close to the spleen (Figure 2),
dissection facilitated by a vessel-sealing device. The
celiac, splenic, and common hepatic arteries are
skeletonized and the nodal tissue swept up the left gastric
artery. The left and right gastric arteries and the
gastroepiploic vessels are ligated at their bases and the
lymph nodes are taken with the specimen. Duodenum is
then divided with a GIA stapler 2 to 3 cm distal to the
pyloric vein (Figure 3). GE junction is mobilized and
esophagus is divided with a transverse anastomosis (TA)
stapler. The specimen is sent to pathology and a frozen
section obtained from the proximal and distal margins of
the specimen to check for adequacy of resection.
Reconstruction after a standard D2 total gastrectomy is by
a Roux-en-Y esophagojejunostomy (Figure 4). We prefer
to perform this with an end-to-end anastomosis (EEA)
stapling device. Alternately a hand-sewn anastomosis or
anastomosis to a jejunal pouch could also be performed. A
jejunostomy feeding tube is placed routinely. We use two
closed suction drains to drain the duodenal stump and the
esophagojejunal anastomosis.
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FIGURE 1 • Mobilization of esophageal hiatus is completed by detaching
the peritoneal reflection from the diaphragm. (From Fischer et al. Mastery
of Surgery. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2007,
with permission.)
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FIGURE 2 • Division of the short gastric vessels close to the spleen. (From
Fischer et al. Mastery of Surgery. 5th ed. Philadelphia, PA: Lippincott
Williams & Wilkins, 2007, with permission.)
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FIGURE 3 • The duodenum being divided with the GIA stapler. (From
Fischer et al. Mastery of Surgery. 5th ed. Philadelphia, PA: Lippincott
Williams & Wilkins, 2007, with permission.)
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