Gastric/Stomach Surgery

Gastric/Stomach Surgery

What is the Stomach?

What is the Stomach?

The stomach is an organ located on the left upper part of the abdomen. Swallowed food is received in the stomach, it is then mixed with acid and digestive enzymes made by the cells of the stomach. The stomach is responsible for grinding and mixing food and is of the first organs of digestion. The stomach muscles contract and push digested food into the intestines.

External Anatomy of the Stomach

External Anatomy of the Stomach

Common Symptoms of Gastric Diseases

Gastric or stomach disease symptoms vary between benign diseases and cancerous diseases. Common symptoms depend on the nature of the problem but in general include:

  • A dull type of abdominal pain in the upper part of the abdomen usually in the midline, but can be on the left or the right areas of the upper abdomen. Pain is due to inflammatory or neoplastic diseases of the stomach.
  • Nausea, upset stomach, feeling full.
  • Vomiting can me due a mechanical or a functional obstruction of the outlet of the stomach, vomiting can include recently digested foods, bile or sometimes blood.
  • Weight loss, poor appetite and aversion to food.

Treating Gastric Diseases

Gastric Cancer – Gastric Tumors

Treatment of gastric cancer should be done by a team of specialists in various medical disciplines, including surgeons/surgical oncologists, medical oncologists, radiation oncologists, gastroenterologists, radiologists, nutritionists and support groups. Gastric cancer treatment is a multimodality treatment and includes surgery, chemotherapy and sometimes radiation therapy. Recent advances include immunotherapy if other treatments fail, in addition to palliative surgery/therapy.

Chemotherapy

Most gastric cancer patients will require chemotherapy at some point in their treatment. Chemotherapy can be given either before or after the tumor has been removed by surgery and depends on treatment team preference and stage of the disease. Surgery on these tumors is technically for curative intention. 

If tumors are too large and involving surrounding organs, and/or have already spread to distant sites other than the stomach, then chemotherapy is given for palliative purposes. Surgery on these patients is also usually palliative and not curative.

Radiation Therapy

Similar to chemotherapy, radiation therapy is an important part of the multimodality approach to gastric cancer, it might be given before or after surgery depending on the stage of the disease and the treatment team preference.

Surgery

Surgery is done as a curative approach or a palliative approach in gastric cancer. As a curative surgery, the goal is to surgically remove the cancer in its entirety. Palliative surgery is performed if the tumor cannot be fully removed, then bypass procedures will be done to correct the stomach obstruction resulting from tumor growth, allowing the patients to eat again.

Gastric Ulcer Diseases

Ulcers are sores or lesions in the inner lining of the stomach. They result from multiple factors, mainly increased acid production by the stomach in addition to weakened defense of the stomach lining. Multiple disease states or medications are linked to gastric ulcers and these include:

  1. Helicobacter Pylori (H. pylori) infection: H. pylori is likely the most common reason for the development of gastric and intestinal ulcers. It damages the lining of the stomach and the intestines and weakens its defense mechanism, allowing for stomach acid to burn through their wall. About 40% of Americans have H. Pylori in their system and most of them remain asymptomatic.
  2. Medications: Non-steroidal anti-inflammatory medications (NSAIDs), like Advil or Motrin or Ibuprofen damage the lining of the stomach allowing for the development of ulcers.
  3. Acid stimulating tumors: some tumors secrete substances that stimulate acid production, the most common example is Gastrinoma, a tumor growing in the stomach or intestines and secretes the Gastrin enzyme which stimulates extra acid production in the stomach, creating severe gastric and duodenal ulcers.

Gastric Ulcer Treatment

With the wide use of acid reducing mediations, surgery for gastric ulcer disease has become rare. Patients are treated with histamine receptor blockers (H2 blockers) or proton pump inhibitors (PPI’s) to reduce the amount of acid and protect the stomach lining. For H. pylori infections, antibiotics and other medications to fight the bacteria and eradiate the bacteria are used. Obviously, if NSAIDs caused the peptic ulcer, a doctor will advise you on how to reduce their use.

Surgery for gastric ulcer disease is almost always nowadays limited to the complications of ulcer disease. If the ulcer is actively bleeding, multiple modalities are used to stop the bleeding and these include endoscopy or embolization of bleeding vessels. Surgery is used as a last resort if other attempts at stopping the bleeding fail. In cases that medication or endoscopic therapy does not work, your doctor may recommend surgery. If the ulcer becomes deep enough to cause a
hole in the wall of the stomach, it becomes an emergency and surgery is most often required to repair the hole.

Surgery of the Stomach

The extent of surgery of the stomach is dictated by the location of the disease, whether done for tumors of the stomach or ulcer disease. Gastric surgery is one of the biggest and most involving surgeries in the abdomen, and that is due to the proximity of the stomach to vital organs, in addition to important blood vessels. 

The stomach is divided into multiple parts: The cardia, fundus, body, antrum and pylorus.

The Gastrectomy Procedure

Surgery to remove part or most of the stomach is a very technically demanding procedure. The decision to remove part of the stomach depends on the location of the disease. A distal gastrectomy is removal of the lower part of the stomach and the pylorus. A total or subtotal gastrectomy is done if the tumor is located more superiorly in the stomach. National guidelines recommend a margin of 4-6 cm away from the tumor when removing a malignant gastric tumor. Depending on the experience and preference of the surgeon and the disease stage and involvement, gastrectomies can be performed either using the open technique of the minimally invasive laparoscopic or robotic technique. 

Types of gastric surgery and mode of reconstruction:

The Gastrectomy Procedure

Palliative Gastric Bypass

When tumors cannot be technically removed by surgery and they are causing a mechanical obstruction for the outflow of food from the stomach, palliative surgery is used to allow these patients to eat again and bypass the area of obstruction. This type of surgery is only done for palliative reasons and is not curative by any means.

Palliative Gastric Bypass