Antrectomy

Definition
Purpose
Demographics
Description
Diagnosis/Preparation
Aftercare
Risks
Normal results
Morbidity and mortality rates
Alternatives

Definition

An antrectomy is the resection, or surgical removal, of a part of the stomach known as the antrum. The antrum is the lower third of the stomach that lies between the body of the stomach and the pyloric canal, which empties into the first part of the small intestine. It is also known as the antrum pyloricum or the gastric antrum. Because an antrectomy is the removal of a portion of the stomach, it is sometimes called a partial or subtotal gastrectomy.

Purpose

An antrectomy may be performed to treat several different disorders that affect the digestive system:

• Peptic ulcer disease (PUD). An antrectomy may be done to treat complications from ulcers that have not responded to medical treatment. These complications include uncontrolled or recurrent bleeding and obstructions that prevent food from passing into the small intestine. Because the antrum produces gastrin, which is a hormone that stimulates the production of stomach acid, its removal lowers the level of acid secretions in the stomach.
• Cancers of the digestive tract and nearby organs. An antrectomy may be performed not only to remove a malignant gastric ulcer, but also to relieve pressure on the lower end of the stomach caused by cancers of the pancreas, gallbladder, or liver.
• Arteriovenous malformations (AVMs) of the stomach. AVMs are collections of small blood vessels that may develop in various parts of the digestive system. AVMs can cause bleeding into the gastrointestinal tract, resulting in hematemesis (vomiting blood) or melena (black or tarry stools containing blood). The type of AVM most likely to occur in the antrum is known as gastric antral vascular ectasia (GAVE) syndrome. The dilated blood vessels in GAVE produce reddish streaks on the wall of the antrum that look like the stripes on a watermelon.
• Gastric outlet obstruction (GOO). GOO is not a single disease or disorder but a condition in which the stomach cannot empty because the pylorus is blocked. In about 37% of cases, the cause of the obstruction is benign—most often PUD, gallstones, bezoars, or scarring caused by ingestion of hydrochloric acid or other caustic substance. The other 63% of cases are caused by pancreatic cancer, gastric cancer, or other malignancy that has spread to the digestive tract.
• Penetrating gunshot or stab wounds that have caused severe damage to the duodenum and pancreas. An antrectomy may be done as an emergency measure when the blood vessels supplying the duodenum have been destroyed.

Demographics

Peptic ulcer disease (PUD) is fairly common in the general United States population. According to the Centers for Disease Control (CDC), about 10% of all Americans will develop an ulcer in the stomach or duodenum at some point in their life. About four million adults are diagnosed or treated each year for PUD; one million will be hospitalized for treatment; and 40,000 will have surgery for an ulcer-related condition. About 6,500 Americans die each year from complications related to PUD. The annual costs to the United States economy from peptic ulcer disease are estimated to be over $6 billion.

Peptic ulcers can develop at any age, but in the United States they are very unusual in children and uncommon in adolescents. Adults between the ages of 30 and 50 are most likely to develop duodenal ulcers, while gastric ulcers are most common in those over 60.

KEY TERMS

Antrum— The lower part of the stomach that lies between the pylorus and the body of the stomach. It is also called the gastric antrum or antrum pyloricum.

Bezoar— A collection of foreign material, usually hair or vegetable fibers or a mixture of both, that may occasionally occur in the stomach or intestines and block the passage of food.

Dumping syndrome— A complex physical reaction to food passing too quickly from the stomach into the small intestine, characterized by sweating, nausea, abdominal cramps, dizziness, and other symptoms.

Duodenum— The first portion of the small intestine, lying between the pylorus and the jejunum.

Dysphagia— Difficulty or discomfort in swallowing.

Endoscopy— A technique for looking inside the stomach or esophagus with the help of a flexible instrument containing a light and miniature video camera on one end.

Gastrin— A hormone produced by cells in the antrum that stimulates the production of gastric acid.

Gastroenterology— The branch of medicine that specializes in the diagnosis and treatment of disorders affecting the stomach and intestines.

Helicobacter pylori— A spiral-shaped bacterium that was discovered in 1982 to be the underlying cause of most ulcers in the stomach and duodenum.

Hematemesis— Vomiting blood.

Melena— The passing of blackish-colored stools containing blood pigments or partially digested blood.

Nonsteroidal anti-inflammatory drugs (NSAIDs)— A term used for a group of analgesics that are often given to arthritis patients. About 20% of peptic ulcers are thought to be caused by frequent use of NSAIDs.

Perforation— An opening or hole in the tissues of the stomach caused by a disease process.

Pylorus— The opening at the lower end of the stomach, encircled by a band of muscle. The contents of the stomach are pumped into the duodenum through the pylorus.

Resection— Removal of an organ or structure. An antrectomy is a resection of the antrum.

Vagotomy— Cutting or dividing various parts of the vagus nerve that supply the stomach. A vagotomy is done to reduce acid secretion.

Watermelon stomach— A type of arteriovenous malformation (AVM) that develops in the antrum. The dilated blood vessels in the AVM resemble the stripes of a watermelon. Watermelon stomach is also known as gastric antral vascular ectasia, or GAVE syndrome.

Duodenal ulcers are more common in men, and gastric ulcers are more common in women. Other risk factors for PUD include heavy smoking and a family history of either duodenal or gastric ulcers.

GAVE, or watermelon stomach, is a very rare cause of gastrointestinal bleeding that was first identified in 1952. It has been associated with such disorders as scleroderma, cirrhosis of the liver, familial Mediterranean fever, and heart disease. GAVE affects women slightly more than twice as often as men. It is almost always found in the elderly; the average age at diagnosis is 73 in women and 68 in men.

Gastric cancer is the 14th most common type of malignant tumor in the United States; however, it occurs much more frequently in Japan and other parts of Asia than in western Europe and North America. About 24,000 people in the United States are diagnosed each year with gastric cancer. Risk factors for developing it include infection of the stomach lining by Helicobacter pylori; Asian American, Hispanic, or African American heritage; age 60 or older; heavy smoking; a history of pernicious anemia; and a diet heavy in dry salted foods. Men are more likely to develop gastric cancer than women. Some doctors think that exposure to certain toxic chemicals in the workplace is also a risk factor for gastric cancer.

Description

At present almost all antrectomies are performed as open procedures, which means that they are done through a large incision in the patient’s abdomen with the patient under general anesthesia. After the patient is anesthetized, a urinary catheter is placed to monitor urinary output, and a nasogastric tube is inserted. After the patient’s abdomen has been cleansed with an antiseptic, the surgeon makes a large incision from the patient’s rib cage to the navel. After separating the overlying layers of tissue, the surgeon exposes the stomach. One clamp is placed at the lower end and another clamp somewhat higher, dividing off the lower third of the stomach. A cutting stapler may be used to remove the lower third (the antrum) and attach the upper portion of the stomach to the small intestine. After the stomach and intestine have been reattached, the area is rinsed with saline solution and the incision closed.

Most antrectomies are performed together with a vagotomy. This is a procedure in which the surgeon cuts various branches of the vagus nerve, which carries messages from the brain to the stomach to secrete more stomach acid. The surgeon may choose to perform a selective vagotomy in order to disable the branches of the nerve that govern gastric secretion without cutting the branches that control stomach emptying.

Some surgeons have performed antrectomies with a laparoscope, which is a less invasive type of surgery. However, as of 2003, this technique is still considered experimental.

Diagnosis/Preparation

Diagnosis

Diagnosis of PUD and other stomach disorders begins with taking the patient’s history, including a family history. In many cases the patient’s primary care physician will order tests in order to narrow the diagnosis. If the patient is older or has lost a large amount of weight recently, the doctor will consider the possibility of gastric cancer. If there is a history of duodenal or gastric ulcers in the patient’s family, the doctor may ask questions about the type of discomfort the patient is experiencing. Pain associated with duodenal ulcers often occurs at night, is relieved at mealtimes, but reappears two to three hours after eating. Pain from gastric ulcers, on the other hand, may be made worse by eating and accompanied by nausea and vomiting. Vomiting that occurs repeatedly shortly after eating suggests a gastric obstruction.

The most common diagnostic tests for stomach disorders are:

• Endoscopy. An endoscope is a thin flexible tube with a light source and video camera on one end that can be passed through the mouth and throat in order to look at the inside of the upper digestive tract. The video camera attached to the endoscope projects images on a computer screen that allow the doctor to see ulcers, tissue growths, and other possible problems. The endoscope can be used to collect tissue cells for a cytology analysis, or a small tissue sample for a biopsy. A tissue biopsy can be used to test for the presence of Helicobacter pylori, a spiral bacterium that was discovered in 1982 to be the underlying cause of most gastric ulcers, as well as to test for cancer. Endoscopy is one of the most effective tests for diagnosing AVMs.
• Double-contrast barium x-ray study of the upper gastrointestinal tract. This test is sometimes called an upper GI series. The patient is given a liquid form of barium to take by mouth. The barium coats the tissues lining the esophagus, stomach, and small intestine, allowing them to be seen more clearly on an x ray. The radiologist can also watch the barium as it moves through the digestive system in order to pinpoint the location of blockages.
• Urease breath test. This test can be used to monitor the effects of ulcer treatment as well as to diagnose the presence of H. pylori. The patient is given urea labeled with either carbon 13-C or 14-C. H. pylori produces urease, which will break down the urea in the test dose to ammonia and carbon dioxide containing the labeled carbon. The carbon dioxide containing the labeled carbon can then be detected in the patient’s breath.

Preparation

Preparation for an antrectomy requires tests to evaluate the patient’s overall health and fitness for surgery. These tests include an EKG, x rays, blood tests, and a urine test. The patient is asked to discontinue aspirin and other blood-thinning medications about a week before surgery. No solid food or liquid should be taken after midnight of the evening before surgery.

In most hospitals the patient will be given a sedative before the operation either intravenously or by injection. The general anesthesia is given in the operating room.

Aftercare

Aftercare in the hospital for an antrectomy is similar to the aftercare given for other operations involving the abdomen, in terms of incision care, pain medication, and antibiotics to minimize the risk of infection. Recuperation at home usually takes several weeks. The patient is given an endoscopic checkup about six to eight weeks after surgery.

The most important aspect of aftercare following an antrectomy is careful attention to diet and eating habits. About 30% of patients who have had an antrectomy or a full gastrectomy develop what is known as dumping syndrome. Dumping syndrome results from food leaving the stomach too quickly after a meal and being “dumped” into the small intestine. There are two types of dumping syndrome, early and late. Early dumping occurs 10–20 minutes after meals and is characterized by feelings of nausea, lightheadedness, sweating, heart palpitations, rapid heartbeat, and abdominal cramps. Late dumping occurs one to three hours after meals high in carbohydrates and is accompanied by feelings of weakness, hunger, and mental confusion. Most patients are able to manage dumping syndrome by eating six small meals per day rather than three larger ones; by choosing foods that are high in protein and low in carbohydrate; by chewing the food thoroughly; and by drinking fluids between rather than with meals.

Risks

In addition to early or late dumping syndrome, other risks associated with antrectomies include:

• Diarrhea. This complication is more likely to occur in patients who had a vagotomy as well as an antrectomy.
• Weight loss. About 30-60% of patients who have had a combined antrectomy/vagotomy lose weight after surgery. The most common cause of weight loss is reduced food intake due to the smaller size of the stomach. In some cases, however, the patient loses weight because the nutrients in the food are not being absorbed by the body.
• Malabsorption/malnutrition. Iron-deficiency anemia, folate deficiency, and loss of calcium sometimes occur after an antrectomy because gastric acid is necessary for iron to be absorbed from food.
• Dysphagia. Dysphagia, or discomfort in swallowing, may occur after an antrectomy when digestive juices from the duodenum flow upward into the esophagus and irritate its lining.
• Recurrence of gastric ulcers.
• Bezoar formation. Bezoars are collections of foreign material (usually vegetable fibers or hair) in the stomach that can block the passage of food into the small intestine. They may develop after an antrectomy if the patient is eating foods high in plant fiber or is not chewing them thoroughly.

Normal results

Normal results of an antrectomy depend on the reasons for the surgery. Antrectomies performed to reduce acid secretion in PUD or to remove premalignant tissue to prevent gastric cancer are over 95% successful. The success rate is even higher in treating watermelon stomach. Antrectomies performed to treat gastric cancer or penetrating abdominal trauma are less successful, but this result is related to the severity of the patient’s illness or injury rather than the surgical procedure itself.

Morbidity and mortality rates

The mortality rate for antrectomies related to ulcer treatment is about 1-2%; for antrectomies related to gastric cancer, 1-3%.

The rates of complications associated with antrectomies for ulcer treatment are:

• Recurrence of ulcer: 0.5-1%.
• Dumping syndromes: 25-30%.
• Diarrhea: 10%.

Alternatives

As of 2003, antrectomy is no longer the first line of treatment for either peptic ulcer disease or GAVE. It is usually reserved for patients with recurrent bleeding or other conditions such as malignancy, perforation, or obstruction.

Although surgery, including antrectomy, is the most common treatment for stomach cancer, it is almost always necessary to combine it with chemotherapy, radiation treatment, or biological therapy (immunotherapy). The reason for a combination of treatments is that stomach cancer is rarely discovered early. Its first symptoms are often mild and easily mistaken for the symptoms of heartburn or a stomach virus. As a result, the cancer has often spread beyond the stomach by the time it is diagnosed.

Medication

Treatment of peptic ulcers caused by H. pylori has changed its focus in recent years from lowering the level of acidity in the stomach to eradicating the bacterium. Since no single antibiotic is effective in curing H. pylori infections, so-called triple therapy typically consists of a combination of one or two antibiotics to kill the bacterium plus a medication to lower acid production and a third medication (usually bismuth subsalicylate) to protect the stomach lining.

Specific types of medications that are used as part of triple therapy or for relief of discomfort include:

• H2 blockers. These are used together with antibiotics in triple therapy to reduce stomach acid secretion. H2 blockers include cimetidine, ranitidine, famotidine, and nizatidine. Some are available as over-the-counter (OTC) medications.
• Proton pump inhibitors. These medications include drugs such as omeprazole and lansoprazole. They are given to suppress production of stomach acid.
• Prostaglandins. These are given to treat ulcers produced by a group of pain medications known as NSAIDs. Prostaglandins protect the stomach lining as well as lower acid secretion. The best-known medication in this category is misoprostol.

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

An antrectomy is performed as an inpatient procedure in a hospital. It is usually performed by a specialist in gastrointestinal surgery or surgical oncology.

• Sucralfate. Sucralfate is a compound of sucrose and aluminum that covers ulcers with a protective coating that allows eroded tissues to heal.
• Antacids. These compounds are available as OTC tablets or liquids.
• Bismuth subsalicylate. Sold as an OTC under the trade name Pepto-Bismol, this medication has some antibacterial effectiveness against H. pylori as well as protecting the stomach lining.

Endoscopy

Endoscopy can be used for treatment as well as diagnosis. About 10 different methods are in use as of 2003 for treating bleeding ulcers and AVMs with the help of an endoscope; the most common involve the injection of epinephrine or a sclerosing solution; the application of a thermal probe to the bleeding area; or the use of an Nd:YAG laser to coagulate the open blood vessels. Watermelon stomach is now treated more often with argon plasma coagulation than with an antrectomy. Recurrent bleeding, however, occurs in 15-20% of ulcers treated with endoscopic methods.

Complementary and alternative (CAM) approaches

Complementary and alternative approaches that have been used to treat gastric ulcers related to PUD include acupuncture, Ayurvedic medicine, and herbal preparations. Ayurvedic medicine, which is the traditional medical system of India, classifies people according to metabolic body type. People who belong to the type known as pitta are considered particularly prone to ulcers and treated with a diet that emphasizes “cooling” foods, including large quantities of vegetables. In Japanese medicine, ulcer remedies made from licorice or bupleurum are frequently prescribed. Western herbalists recommend preparations containing fennel, fenugreek, slippery elm, or marshmallow root

QUESTIONS TO ASK THE DOCTOR

• What are the alternatives to an antrectomy for my condition? Which would you recommend and why?
• How many antrectomies have you performed?
• How likely am I to develop dumping syndrome if I have the procedure?
• What is your opinion of laparoscopic antrectomies? Would I be eligible to participate in a clinical study of this procedure?

in addition to licorice to relieve the pain of stomach ulcers.

Resources

BOOKS

“Arteriovenous Malformations.” In The Merck Manual of Diagnosis and Therapy, edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 1999.

Pelletier, Kenneth R., MD. The Best Alternative Medicine, Part II, “CAM Therapies for Specific Conditions: Ulcers.” New York: Simon & Schuster, 2002.

“Peptic Ulcer Disease.” In The Merck Manual of Diagnosis and Therapy, edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 1999.

Thomson, A. B. R. and E. A. Shaffer. First Principles of Gastroenterology, 3rd ed. Oakville, ON: Canadian Association of Gastroenterology, 2002.

PERIODICALS

Appleyard, M. N. and C. P. Swain. “Endoscopic Difficulties in the Diagnosis of Upper Gastrointestinal Bleeding.” World Journal of Gastroenterology 7 (2001): 308–12.

Busteed, S., C. Silke, C. Molloy, et al. “Gastric Antral Vascular Ectasia—A Cause of Refractory Anaemia in Systemic Sclerosis.” Irish Medical Journal 94 (November-December 2001): 310.

Castellanos, Andres, MD, Barry D. Mann, MD, and James de Caestecker, DO. “Gastric Outlet Obstruction.” eMedicine, February 12, 2002 [cited April 27, 2003]. www.emedicine.com/med/topic2713.htm.

De Caestecker, James, DO. “Upper Gastrointestinal Bleeding: Surgical Perspective.” eMedicine, October 17, 2002 [cited April 27, 2003]. www.emedicine.com/med/topic3566.htm.

Fowler, Dennis, MD. “Laparoscopic Foregut Surgery: Less Commonly Performed Procedures.” Minimal Access Surgery Center Newsletter, New York-Presbyterian Hospital 2 (Winter 2002): 7–10.

Komar, Aleksander R., MD and Prem Patel, MD. “Abdominal Trauma, Penetrating.” eMedicine, April 25, 2002 [cited April 28, 2003]. www.emedicine.com/med/topic2805.htm.

Probst, A., R. Scheubel, and M. Wienbeck. “Treatment of Watermelon Stomach (GAVE Syndrome) by Means of Endoscopic Argon Plasma Coagulation (APC): Long-Term Outcome.” Zeitschrift fur Gastroenterologie 39 (June 2001): 447–52.

Stotzer, P. O., R. Willen, and A. F. Kilander. “Watermelon Stomach: Not Only an Antral Disease.” Gastrointestinal Endoscopy 55 (June 2002): 897–900.

Tseng, Y. L., M. H. Wu, M. Y. Lin, and W. W. Lai. “Early Surgical Correction for Isolated Gastric Stricture Following Acid Corrosion Injury.” Digestive Surgery 19 (2002): 276–80.

Yusoff, I., F. Brennan, D. Ormonde, and B. Laurence. “Argon Plasma Coagulation for Treatment of Watermelon Stomach.” Endoscopy 34 (May 2002): 407–10.

Zarzaur, B. L., K. A. Kudsk, K. Carter, et al. “Stress Ulceration Requiring Definitive Surgery After Severe Trauma.” American Surgeon 67 (September 2001): 875–79.

ORGANIZATIONS

American Gastroenterological Association (AGA). 4930 Del Ray Avenue, Bethesda, MD 20814. (301) 654-2055. www.gastro.org.

American Society for Gastrointestinal Endoscopy (ASGE). 1520 Kensington Road, Suite 202, Oak Brook, IL 60523 (630) 573-0600. www.asge.org.

Canadian Association of Gastroenterology (CAG). 2902 South Sheridan Way, Oakville, ON L6J 7L6 (888) 780-0007 or (905) 829-2504. www.cag-acg.org.

Centers for Disease Control and Prevention (CDC). 1600 Clifton Road, Atlanta, GA 30333. (888) MY-ULCER or (404) 639-3534. www.cdc.gov.

National Cancer Institute (NCI). NCI Public Inquiries Office, Suite 3036A, 6116 Executive Boulevard, MSC8332, Bethesda, MD 20892-8322. (800) 4-CANCER or (800) 332-8615 (TTY). www.nci.nih.gov.

National Digestive Diseases Information Clearinghouse (NDDIC). 2 Information Way, Bethesda, MD 20892-3570. www.niddk.nih.gov/health/digest/pubs.

OTHER

National Cancer Institute (NCI) Physician Data Query (PDQ). Gastric Cancer: Treatment, January 2, 2003 [cited April 28, 2003]. www.nci.nih.gov/cancerinfo/pdq/treatment/gastric/healthprofessional.

National Digestive Diseases Information Clearinghouse (NDDIC). What I Need to Know About Peptic Ulcers, August 2002 [cited April 28, 2003]. NIH Publication No. 02-5042. www.niddk.nih.gov/health/digest/pubs/pepticulcers/pepticulcers.htm.

Rebecca Frey, Ph.D.

Anxiolytics seeAntianxiety drugs

Antrectomy

Definition

An antrectomy is the resection, or surgical removal, of a part of the stomach known as the antrum. The antrum is the lower third of the stomach that lies between the body of the stomach and the pyloric canal, which empties into the first part of the small intestine. It is also known as the antrum pyloricum or the gastric antrum. Because an antrectomy is the removal of a portion of the stomach, it is sometimes called a partial or subtotal gastrectomy .

Purpose

An antrectomy may be performed to treat several different disorders that affect the digestive system:

• Peptic ulcer disease (PUD). An antrectomy may be done to treat complications from ulcers that have not responded to medical treatment. These complications include uncontrolled or recurrent bleeding and obstructions that prevent food from passing into the small intestine. Because the antrum produces gastrin, which is a hormone that stimulates the production of stomach acid, its removal lowers the level of acid secretions in the stomach.
• Cancers of the digestive tract and nearby organs. An antrectomy may be performed not only to remove a malignant gastric ulcer, but also to relieve pressure on the lower end of the stomach caused by cancers of the pancreas, gallbladder, or liver.
• Arteriovenous malformations (AVMs) of the stomach. AVMs are collections of small blood vessels that may develop in various parts of the digestive system. AVMs can cause bleeding into the gastrointestinal tract, resulting in hematemesis (vomiting blood) or melena (black or tarry stools containing blood). The type of AVM most likely to occur in the antrum is known as gastric antral vascular ectasia (GAVE) syndrome. The dilated blood vessels in GAVE produce reddish streaks on the wall of the antrum that look like the stripes on a watermelon.
• Gastric outlet obstruction (GOO). GOO is not a single disease or disorder but a condition in which the stomach cannot empty because the pylorus is blocked. In about 37% of cases, the cause of the obstruction is be nign—most often PUD, gallstones, bezoars, or scarring caused by ingestion of hydrochloric acid or other caustic substance. The other 63% of cases are caused by pancreatic cancer, gastric cancer, or other malignancy that has spread to the digestive tract.
• Penetrating gunshot or stab wounds that have caused severe damage to the duodenum and pancreas. An antrectomy may be done as an emergency measure when the blood vessels supplying the duodenum have been destroyed.

Demographics

Peptic ulcer disease (PUD) is fairly common in the general United States population. According to the Centers for Disease Control (CDC), about 10% of all Americans will develop an ulcer in the stomach or duodenum at some point in their life. About four million adults are diagnosed or treated each year for PUD; one million will be hospitalized for treatment; and 40,000 will have surgery for an ulcer-related condition. About 6,500 Americans die each year from complications related to PUD. The annual costs to the United States economy from peptic ulcer disease are estimated to be over $6 billion.

Peptic ulcers can develop at any age, but in the United States they are very unusual in children and uncommon in adolescents. Adults between the ages of 30 and 50 are most likely to develop duodenal ulcers, while gastric ulcers are most common in those over 60. Duodenal ulcers are more common in men, and gastric ulcers are more common in women. Other risk factors for PUD include heavy smoking and a family history of either duodenal or gastric ulcers.

GAVE, or watermelon stomach, is a very rare cause of gastrointestinal bleeding that was first identified in 1952. It has been associated with such disorders as scleroderma, cirrhosis of the liver, familial Mediterranean fever, and heart disease. GAVE affects women slightly more than twice as often as men. It is almost always found in the elderly; the average age at diagnosis is 73 in women and 68 in men.

Gastric cancer is the 14th most common type of malignant tumor in the United States; however, it occurs much more frequently in Japan and other parts of Asia than in western Europe and North America. About 24,000 people in the United States are diagnosed each year with gastric cancer. Risk factors for developing it include infection of the stomach lining by Helicobacter pylori ; Asian American, Hispanic, or African American heritage; age 60 or older; heavy smoking; a history of pernicious anemia; and a diet heavy in dry salted foods. Men are more likely to develop gastric cancer than women. Some doctors think that exposure to certain toxic chemicals in the workplace is also a risk factor for gastric cancer.

Description

At present almost all antrectomies are performed as open procedures, which means that they are done through a large incision in the patient's abdomen with the patient under general anesthesia. After the patient is anesthetized, a urinary catheter is placed to monitor urinary output, and a nasogastric tube is inserted. After the patient's abdomen has been cleansed with an antiseptic, the surgeon makes a large incision from the patient's rib cage to the navel. After separating the overlying layers of tissue, the surgeon exposes the stomach. One clamp is placed at the lower end and another clamp somewhat higher, dividing off the lower third of the stomach. A cutting stapler may be used to remove the lower third (the antrum) and attach the upper portion of the stomach to the small intestine. After the stomach and intestine have been reattached, the area is rinsed with saline solution and the incision closed.

Most antrectomies are performed together with a vagotomy . This is a procedure in which the surgeon cuts various branches of the vagus nerve, which carries messages from the brain to the stomach to secrete more stomach acid. The surgeon may choose to perform a selective vagotomy in order to disable the branches of the nerve that govern gastric secretion without cutting the branches that control stomach emptying.

Some surgeons have performed antrectomies with a laparoscope, which is a less invasive type of surgery. However, as of 2003, this technique is still considered experimental.

Diagnosis/Preparation

Diagnosis

Diagnosis of PUD and other stomach disorders begins with taking the patient's history, including a family history. In many cases the patient's primary care physician will order tests in order to narrow the diagnosis. If the patient is older or has lost a large amount of weight recently, the doctor will consider the possibility of gastric cancer. If there is a history of duodenal or gastric ulcers in the patient's family, the doctor may ask questions about the type of discomfort the patient is experiencing. Pain associated with duodenal ulcers often occurs at night, is relieved at mealtimes, but reappears two to three hours after eating. Pain from gastric ulcers, on the other hand, may be made worse by eating and accompanied by nausea and vomiting. Vomiting that occurs repeatedly shortly after eating suggests a gastric obstruction.

The most common diagnostic tests for stomach disorders are:

• Endoscopy. An endoscope is a thin flexible tube with a light source and video camera on one end that can be passed through the mouth and throat in order to look at the inside of the upper digestive tract. The video camera attached to the endoscope projects images on a computer screen that allow the doctor to see ulcers, tissue growths, and other possible problems. The endoscope can be used to collect tissue cells for a cytology analysis, or a small tissue sample for a biopsy. A tissue biopsy can be used to test for the presence of Helicobacter pylori, a spiral bacterium that was discovered in 1982 to be the underlying cause of most gastric ulcers, as well as to test for cancer. Endoscopy is one of the most effective tests for diagnosing AVMs.
• Double-contrast barium x-ray study of the upper gastrointestinal tract. This test is sometimes called an upper GI series. The patient is given a liquid form of barium to take by mouth. The barium coats the tissues lining the esophagus, stomach, and small intestine, allowing them to be seen more clearly on an x ray. The radiologist can also watch the barium as it moves through the digestive system in order to pinpoint the location of blockages.
• Urease breath test. This test can be used to monitor the effects of ulcer treatment as well as to diagnose the presence of H. pylori. The patient is given urea labeled with either carbon 13-C or 14-C. H. pylori produces urease, which will break down the urea in the test dose to ammonia and carbon dioxide containing the labeled carbon. The carbon dioxide containing the labeled carbon can then be detected in the patient's breath.

Preparation

Preparation for an antrectomy requires tests to evaluate the patient's overall health and fitness for surgery. These tests include an EKG, x rays, blood tests, and a urine test. The patient is asked to discontinue aspirin and other blood-thinning medications about a week before surgery. No solid food or liquid should be taken after midnight of the evening before surgery.

In most hospitals the patient will be given a sedative before the operation either intravenously or by injection. The general anesthesia is given in the operating room .

Aftercare

Aftercare in the hospital for an antrectomy is similar to the aftercare given for other operations involving the abdomen, in terms of incision care , pain medication, and antibiotics to minimize the risk of infection. Recuperation at home usually takes several weeks. The patient is given an endoscopic check-up about six to eight weeks after surgery.

The most important aspect of aftercare following an antrectomy is careful attention to diet and eating habits. About 30% of patients who have had an antrectomy or a full gastrectomy develop what is known as dumping syndrome. Dumping syndrome results from food leaving the stomach too quickly after a meal and being "dumped" into the small intestine. There are two types of dumping syndrome, early and late. Early dumping occurs 10–20 minutes after meals and is characterized by feelings of nausea, lightheadedness, sweating, heart palpitations, rapid heartbeat, and abdominal cramps. Late dumping occurs one to three hours after meals high in carbohydrates and is accompanied by feelings of weakness, hunger, and mental confusion. Most patients are able to manage dumping syndrome by eating six small meals per day rather than three larger ones; by choosing foods that are high in protein and low in carbohydrate; by chewing the food thoroughly; and by drinking fluids between rather than with meals.

Risks

In addition to early or late dumping syndrome, other risks associated with antrectomies include:

• Diarrhea. This complication is more likely to occur in patients who had a vagotomy as well as an antrectomy.
• Weight loss. About 30–60% of patients who have had a combined antrectomy/vagotomy lose weight after surgery. The most common cause of weight loss is reduced food intake due to the smaller size of the stomach. In some cases, however, the patient loses weight because the nutrients in the food are not being absorbed by the body.
• Malabsorption/malnutrition. Iron-deficiency anemia, folate deficiency, and loss of calcium sometimes occur after an antrectomy because gastric acid is necessary for iron to be absorbed from food.
• Dysphagia. Dysphagia, or discomfort in swallowing, may occur after an antrectomy when digestive juices from the duodenum flow upward into the esophagus and irritate its lining.
• Recurrence of gastric ulcers.
• Bezoar formation. Bezoars are collections of foreign material (usually vegetable fibers or hair) in the stomach that can block the passage of food into the small intestine. They may develop after an antrectomy if the patient is eating foods high in plant fiber or is not chewing them thoroughly.

Normal results

Normal results of an antrectomy depend on the reasons for the surgery. Antrectomies performed to reduce acid secretion in PUD or to remove premalignant tissue to prevent gastric cancer are over 95% successful. The success rate is even higher in treating watermelon stomach. Antrectomies performed to treat gastric cancer or penetrating abdominal trauma are less successful, but this result is related to the severity of the patient's illness or injury rather than the surgical procedure itself.

Morbidity and mortality rates

The mortality rate for antrectomies related to ulcer treatment is about 1–2%; for antrectomies related to gastric cancer, 1%–3%.

The rates of complications associated with antrectomies for ulcer treatment are:

• Recurrence of ulcer: 0.5%–1%.
• Dumping syndromes: 25%–30%.
• Diarrhea: 10%.

Alternatives

As of 2003, antrectomy is no longer the first line of treatment for either peptic ulcer disease or GAVE. It is usually reserved for patients with recurrent bleeding or other conditions such as malignancy, perforation, or obstruction.

Although surgery, including antrectomy, is the most common treatment for stomach cancer, it is almost always necessary to combine it with chemotherapy, radiation treatment, or biological therapy (immunotherapy). The reason for a combination of treatments is that stomach cancer is rarely discovered early. Its first symptoms are often mild and easily mistaken for the symptoms of heartburn or a stomach virus. As a result, the cancer has often spread beyond the stomach by the time it is diagnosed.

Medication

Treatment of peptic ulcers caused by H. pylori has changed its focus in recent years from lowering the level of acidity in the stomach to eradicating the bacterium. Since no single antibiotic is effective in curing H. pylori infections, so-called triple therapy typically consists of a combination of one or two antibiotics to kill the bacterium plus a medication to lower acid production and a third medication (usually bismuth subsalicylate) to protect the stomach lining.

Specific types of medications that are used as part of triple therapy or for relief of discomfort include:

• H2 blockers. These are used together with antibiotics in triple therapy to reduce stomach acid secretion. H2 blockers include cimetidine, ranitidine, famotidine, and nizatidine. Some are available as over-the-counter (OTC) medications.
• Proton pump inhibitors. These medications include drugs such as omeprazole and lansoprazole. They are given to suppress production of stomach acid.
• Prostaglandins. These are given to treat ulcers produced by a group of pain medications known as NSAIDs. Prostaglandins protect the stomach lining as well as lower acid secretion. The best-known medication in this category is misoprostol.
• Sucralfate. Sucralfate is a compound of sucrose and aluminum that covers ulcers with a protective coating that allows eroded tissues to heal.
• Antacids. These compounds are available as OTC tablets or liquids.
• Bismuth subsalicylate. Sold as an OTC under the trade name Pepto-Bismol, this medication has some antibacterial effectiveness against H. pylori as well as protecting the stomach lining.

Endoscopy

Endoscopy can be used for treatment as well as diagnosis. About 10 different methods are in use as of 2003 for treating bleeding ulcers and AVMs with the help of an endoscope; the most common involve the injection of epinephrine or a sclerosing solution; the application of a thermal probe to the bleeding area; or the use of a Nd:YAG laser to coagulate the open blood vessels. Watermelon stomach is now treated more often with argon plasma coagulation than with an antrectomy. Recurrent bleeding, however, occurs in 15–20% of ulcers treated with endoscopic methods.

Complementary and alternative (CAM) approaches

Complementary and alternative approaches that have been used to treat gastric ulcers related to PUD include acupuncture, Ayurvedic medicine, and herbal preparations. Ayurvedic medicine, which is the traditional medical system of India, classifies people according to metabolic body type. People who belong to the type known as pitta are considered particularly prone to ulcers and treated with a diet that emphasizes "cooling" foods, including large quantities of vegetables. In Japanese medicine, ulcer remedies made from licorice or bupleurum are frequently prescribed. Western herbalists recommend preparations containing fennel, fenugreek, slippery elm, or marshmallow root in addition to licorice to relieve the pain of stomach ulcers.

See also Gastrectomy.

Resources

books

"Arteriovenous Malformations." In The Merck Manual of Diagnosis and Therapy, edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 1999.

Pelletier, Kenneth R., MD. The Best Alternative Medicine, Part II, "CAM Therapies for Specific Conditions: Ulcers." New York: Simon & Schuster, 2002.

"Peptic Ulcer Disease." In The Merck Manual of Diagnosis and Therapy, edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 1999.

Thomson, A. B. R. and E. A. Shaffer. First Principles of Gastroenterology, 3rd ed. Oakville, ON: Canadian Association of Gastroenterology, 2002.

periodicals

Appleyard, M. N. and C. P. Swain. "Endoscopic Difficulties in the Diagnosis of Upper Gastrointestinal Bleeding." World Journal of Gastroenterology 7 (2001): 308-12.

Busteed, S., C. Silke, C. Molloy, et al. "Gastric Antral Vascular Ectasia—A Cause of Refractory Anaemia in Systemic Sclerosis." Irish Medical Journal 94 (November-December 2001): 310.

Castellanos, Andres, MD, Barry D. Mann, MD, and James de Caestecker, DO. "Gastric Outlet Obstruction." eMedicine, February 12, 2002 [cited April 27, 2003]. <www.emedicine.com/med/topic2713.htm>.

De Caestecker, James, DO. "Upper Gastrointestinal Bleeding: Surgical Perspective." eMedicine, October 17, 2002 [cited April 27, 2003]. <www.emedicine.com/med/topic3566.htm>.

Fowler, Dennis, MD. "Laparoscopic Foregut Surgery: Less Commonly Performed Procedures." Minimal Access Surgery Center Newsletter, New York-Presbyterian Hospital 2 (Winter 2002): 7–10.

Komar, Aleksander R., MD and Prem Patel, MD. "Abdominal Trauma, Penetrating." eMedicine, April 25, 2002 [cited April 28, 2003]. <www.emedicine.com/med/topic2805.htm>.

Probst, A., R. Scheubel, and M. Wienbeck. "Treatment of Watermelon Stomach (GAVE Syndrome) by Means of Endoscopic Argon Plasma Coagulation (APC): Long-Term Outcome." Zeitschrift für Gastroenterologie 39 (June 2001): 447-52.

Stotzer, P. O., R. Willen, and A. F. Kilander. "Watermelon Stomach: Not Only an Antral Disease." Gastrointestinal Endoscopy 55 (June 2002): 897–900.

Tseng, Y. L., M. H. Wu, M. Y. Lin, and W. W. Lai. "Early Surgical Correction for Isolated Gastric Stricture Following Acid Corrosion Injury." Digestive Surgery 19 (2002): 276–80.

Yusoff, I., F. Brennan, D. Ormonde, and B. Laurence. "Argon Plasma Coagulation for Treatment of Watermelon Stomach." Endoscopy 34 (May 2002): 407–10.

Zarzaur, B. L., K. A. Kudsk, K. Carter, et al. "Stress Ulceration Requiring Definitive Surgery After Severe Trauma." American Surgeon 67 (September 2001): 875–79.

organizations

American Gastroenterological Association (AGA). 4930 Del Ray Avenue, Bethesda, MD 20814. (301) 654-2055. <www.gastro.org>.

American Society for Gastrointestinal Endoscopy (ASGE). 1520 Kensington Road, Suite 202, Oak Brook, IL 60523 (630) 573-0600. <www.asge.org>.

Canadian Association of Gastroenterology (CAG). 2902 South Sheridan Way, Oakville, ON L6J 7L6 (888) 780-0007 or (905) 829-2504. <www.cag-acg.org>.

Centers for Disease Control and Prevention (CDC). 1600 Clifton Road, Atlanta, GA 30333. (888) MY-ULCER or (404) 639-3534. <www.cdc.gov>.

National Cancer Institute (NCI). NCI Public Inquiries Office, Suite 3036A, 6116 Executive Boulevard, MSC8332, Bethesda, MD 20892-8322. (800) 4-CANCER or (800) 332-8615 (TTY). <www.nci.nih.gov>.

National Digestive Diseases Information Clearinghouse (NDDIC). 2 Information Way, Bethesda, MD 20892-3570. <www.niddk.nih.gov/health/digest/pubs>.

other

National Cancer Institute (NCI) Physician Data Query (PDQ). Gastric Cancer: Treatment, January 2, 2003 [cited April 28, 2003]. <www.nci.nih.gov/cancerinfo/pdq/treatment/gastric/healthprofessional>.

National Digestive Diseases Information Clearinghouse (NDDIC). What I Need to Know About Peptic Ulcers,August 2002 [cited April 28, 2003]. NIH Publication No. 02-5042. <www.niddk.nih.gov/health/digest/pubs/pepticulcers/pepticulcers.htm>.

Rebecca Frey, Ph.D.

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

An antrectomy is performed as an inpatient procedure in a hospital. It is usually performed by a specialist in gastrointestinal surgery or surgical oncology .

QUESTIONS TO ASK THE DOCTOR

• What are the alternatives to an antrectomy for my condition? Which would you recommend and why?
• How many antrectomies have you performed?
• How likely am I to develop dumping syndrome if I have the procedure?
• What is your opinion of laparoscopic antrectomies? Would I be eligible to participate in a clinical study of this procedure?

Gastrectomy

Definition

Gastrectomy is the surgical removal of all or part of the stomach.

Purpose

Gastrectomy is performed most commonly to treat the following conditions:

• stomach cancer
• bleeding gastric ulcer
• perforation of the stomach wall
• noncancerous polyps

Demographics

Stomach cancer was the most common form of cancer worldwide in the 1970s and early 1980s, and the incidence rates have always shown substantial variation in different countries. Rates are currently highest in Japan and eastern Asia, but other areas of the world have high incidence rates, including Eastern European countries and parts of Latin America. Incidence rates are generally lower in Western Europe and the United States.

Gastrointestinal diseases (including gastric ulcers) affect an estimated 25–30% of the world's population. In the United States, 60 million adults experience gastrointestinal reflux at least once a month, and 25 million adults suffer daily from heartburn, a condition that may evolve into ulcers.

Description

Gastrectomy for cancer

Removal of the tumor, often with removal of the surrounding lymph nodes, is the only curative treatment for various forms of gastric (stomach) cancer. For many patients, this entails removing not only the tumor, but part of the stomach as well. The extent to which lymph nodes should also be removed is a subject of debate, but some studies show additional survival benefits associated with removal of a greater number of lymph nodes.

Gastrectomy, either total or subtotal (also called partial), is the treatment of choice for gastric adenocarcinomas, primary gastric lymphomas (originating in the stomach), and the rare leiomyosarcomas (also called gastric sarcomas). Adenocarcinomas are by far the most common form of stomach cancer and are less curable than the relatively uncommon lymphomas, for which gastrectomy offers good chances of survival.

General anesthesia is used to ensure that the patient does not experience pain and is not conscious during the operation. When the anesthesia has taken hold, a urinary catheter is usually inserted to monitor urine output. A thin nasogastric tube is inserted from the nose down into the stomach. The abdomen is cleansed with an antiseptic solution. The surgeon makes a large incision from just below the breastbone down to the navel. If the lower end of the stomach is diseased, the surgeon places clamps on either end of the area, and that portion is excised. The upper part of the stomach is then attached to the small intestine. If the upper end of the stomach is diseased, the end of the esophagus and the upper part of the stomach are clamped together. The diseased part is removed, and the lower part of the stomach is attached to the esophagus.

After gastrectomy, the surgeon may reconstruct the altered portions of the digestive tract so that it may continue to function. Several different surgical techniques are used, but, generally speaking, the surgeon attaches any remaining portion of the stomach to the small intestine.

Gastrectomy for gastric cancer is almost always done using the traditional open surgery technique, which requires a wide incision to open the abdomen. However, some surgeons use a laparoscopic technique that requires only a small incision. The laparoscope is connected to a tiny video camera that projects a picture of the abdominal contents onto a monitor for the surgeon's viewing. The stomach is operated on through this incision.

The potential benefits of laparoscopic surgery include less postoperative pain, decreased hospitalization, and earlier return to normal activities. The use of laparoscopic gastrectomy is limited, however. Only patients with early-stage gastric cancers or those whose surgery is intended only for palliation (pain and symptomatic relief rather than cure) are considered for this minimally invasive technique. It can only be performed by surgeons experienced in this type of surgery.

Gastrectomy for ulcers

Gastrectomy is also occasionally used in the treatment of severe peptic ulcer disease or its complications. While the vast majority of peptic ulcers (gastric ulcers in the stomach or duodenal ulcers in the duodenum) are managed with medication, partial gastrectomy is sometimes required for peptic ulcer patients who have complications. These include patients who do not respond satisfactorily to medical therapy; those who develop a bleeding or perforated ulcer; and those who develop pyloric obstruction, a blockage to the exit from the stomach.

The surgical procedure for severe ulcer disease is also called an antrectomy , a limited form of gastrectomy in which the antrum, a portion of the stomach, is removed. For duodenal ulcers, antrectomy may be combined with other surgical procedures that are aimed at reducing the secretion of gastric acid, which is associated with ulcer formation. This additional surgery is commonly a vagotomy , surgery on the vagus nerve that disables the acid-producing portion of the stomach.

Diagnosis/Preparation

Before undergoing gastrectomy, patients require a variety of such tests as x rays, computed tomography (CT) scans, ultrasonography, or endoscopic biopsies (microscopic examination of tissue) to confirm the diagnosis and localize the tumor or ulcer. Laparoscopy may be done to diagnose a malignancy or to determine the extent of a tumor that is already diagnosed. When a tumor is strongly suspected, laparoscopy is often performed immediately before the surgery to remove the tumor; this method avoids the need to anesthetize the patient twice and sometimes avoids the need for surgery altogether if the tumor found on laparoscopy is deemed inoperable.

Aftercare

After gastrectomy surgery, patients are taken to the recovery unit and vital signs are closely monitored by the nursing staff until the anesthesia wears off. Patients commonly feel pain from the incision, and pain medication is prescribed to provide relief, usually delivered intravenously. Upon waking from anesthesia, patients have an intravenous line, a urinary catheter, and a nasogastric tube in place. They cannot eat or drink immediately following surgery. In some cases, oxygen is delivered through a mask that fits over the mouth and nose. The nasogastric tube is attached to intermittent suction to keep the stomach empty. If the whole stomach has been removed, the tube goes directly to the small intestine and remains in place until bowel function returns, which can take two to three days and is monitored by listening with a stethoscope for bowel sounds. A bowel movement is also a sign of healing. When bowel sounds return, the patient can drink clear liquids. If the liquids are tolerated, the nasogastric tube is removed and the diet is gradually changed from liquids to soft foods, and then to more solid foods. Dietary adjustments may be necessary, as certain foods may now be difficult to digest. Overall, gastrectomy surgery usually requires a recuperation time of several weeks.

Risks

Surgery for peptic ulcer is effective, but it may result in a variety of postoperative complications. Following gastrectomy surgery, as many as 30% of patients have significant symptoms. An operation called highly selective vagotomy is now preferred for ulcer management, and is safer than gastrectomy.

After a gastrectomy, several abnormalities may develop that produce symptoms related to food intake. They happen largely because the stomach, which serves as a food reservoir, has been reduced in its capacity by the surgery. Other surgical procedures that often accompany gastrectomy for ulcer disease can also contribute to later symptoms. These procedures include vagotomy, which lessens acid production and slows stomach emptying; and pyloroplasty , which enlarges the opening between the stomach and small intestine to facilitate emptying of the stomach.

Some patients experience lightheadedness, heart palpitations or racing heart, sweating, and nausea and vomiting after a meal. These may be symptoms of "dumping syndrome," as food is rapidly dumped into the small intestine from the stomach. Dumping syndrome is treated by adjusting the diet and pattern of eating, for example, eating smaller, more frequent meals and limiting liquids.

Patients who have abdominal bloating and pain after eating, frequently followed by nausea and vomiting, may have what is called the "afferent loop syndrome." This is treated by surgical correction. Patients who have early satiety (feeling of fullness after eating), abdominal discomfort, and vomiting may have bile reflux gastritis (also called bilious vomiting), which is also surgically correctable. Many patients also experience weight loss.

Reactive hypoglycemia is a condition that results when blood sugar levels become too high after a meal, stimulating the release of insulin, occurring about two hours after eating. A high-protein diet and smaller meals are advised.

Ulcers recur in a small percentage of patients after surgery for peptic ulcer, usually in the first few years. Further surgery is usually necessary.

Vitamin and mineral supplementation is necessary after gastrectomy to correct certain deficiencies, especially vitamin B12, iron, and folate. Vitamin D and calcium are also needed to prevent and treat the bone problems that often occur. These include softening and bending of the bones, which can produce pain and osteoporosis, a loss of bone mass. According to one study, the risk for spinal fractures may be as high as 50% after gastrectomy.

Normal results

Overall survival after gastrectomy for gastric cancer varies greatly by the stage of disease at the time of surgery. For early gastric cancer, the five-year survival rate is as high as 80–90%; for late-stage disease, the prognosis is bad. For gastric adenocarcinomas that are amenable to gastrectomy, the five-year survival rate is 10–30%, depending on the location of the tumor. The prognosis for patients with gastric lymphoma is better, with five-year survival rates reported at 40–60%.

Most studies have shown that patients can have an acceptable quality of life after gastrectomy for a potentially curable gastric cancer. Many patients will maintain a healthy appetite and eat a normal diet. Others may lose weight and not enjoy meals as much. Some studies show that patients who have total gastrectomies have more disease-related or treatment-related symptoms after surgery and poorer physical function than patients who have subtotal gastrectomies. There does not appear to be much difference, however, in emotional status or social activity level between patients who have undergone total versus subtotal gastrectomies.

Morbidity and mortality rates

Depending on the extent of surgery, the risk for postoperative death after gastrectomy for gastric cancer has been reported as 1–3% and the risk of non-fatal complications as 9–18%. Overall, gastric cancer incidence and mortality rates have been declining for several decades in most areas of the world.

Resources

books

"Disorders of the Stomach and Duodenum." In The Merck Manual. Whitehouse Station, NJ: Merck & Co., Inc., 1992.

"Stomach and Duodenum: Complications of Surgery for Peptic Ulcer Disease." In Sleisenger & Fordtran's Gastrointestinal and Liver Disease, edited by Mark Feldman et al. Philadelphia: W. B. Saunders Co., 1998.

periodicals

Fujiwara, M., et al. "Laparoscopy-Assisted Distal Gastrectomy with Systemic Lymph Node Dissection for Early Gastric Carcinoma: A Review of 43 Cases." Journal of the American College of Surgeons 196 (January 2003): 75–81.

Iseki, J., et al. "Feasibility of Central Gastrectomy for Gastric Cancer." Surgery 133 (January 2003): 75–81.

Kim, Y. W., H. S. Han, and G. D. Fleischer. "Hand-Assisted Laparoscopic Total Gastrectomy." Surgical Laparoscopy, Endoscopy & Percutaneous Techniques 13 (February 2003): 26–30.

Kono, K., et al. "Improved Quality of Life with Jejunal Pouch Reconstruction after Total Gastrectomy." American Journal of Surgery 185 (February 2003): 150–154.

organizations

American College of Gastroenterology. 4900-B South 31st St., Arlington, VA 22206. (703) 820-7400. <www.acg.gi.org>.

American Gastroenterological Association (AGA). 4930 Del Ray Avenue, Bethesda, MD 20814. (301) 654-2055. <www.gastro.org>.

other

Mayo Clinic Online: Gastrectomy. <www.mayohealth.com>.

Caroline A. Helwick
Monique Laberge, PhD

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

A gastrectomy is performed by a surgeon trained in gastroenterology, the branch of medicine that deals with the diseases of the digestive tract. An anesthesiologist is responsible for administering anesthesia, and the operation is performed in a hospital setting.

QUESTIONS TO ASK THE DOCTOR

• What happens on the day of surgery?
• What type of anesthesia will be used?
• How long will it take to recover from the surgery?
• When can I expect to return to work and/or resume normal activities?
• What are the risks associated with a gastrectomy?
• How many gastrectomies do you perform in a year?
• Will there be a scar?

Gastrectomy

Definition
Purpose
Demographics
Description
Diagnosis/Preparation
Aftercare
Risks
Normal results
Morbidity and mortality rates

Definition

Gastrectomy is the surgical removal of all or part of the stomach.

Purpose

Gastrectomy is performed most often to treat the following conditions:

• stomach (gastric) cancer
• bleeding gastric ulcer
• perforation of the stomach wall
• noncancerous tumors

Demographics

According to the World Health Organization (WHO), stomach cancer is the second leading cause of cancer deaths in the world, accounting for about 8.8% of all deaths from cancer. (Lung cancer accounts for 17.8% of cancer deaths). Although stomach cancer is a worldwide problem, the incidence rates vary considerably in different countries. In the 2000s, the highest death rates from stomach cancer are found in Japan, South America, especially Chile, and parts of the former Soviet Union. In the United States, the American Cancer Society expected about 21,300 new cases of stomach cancer to be diagnosed and 11,000 deaths to be attributed to the disease. Since gastrectomy is most often done to treat stomach cancer, gastrectomy rates should mirror stomach cancer rates.

Description

Gastrectomy for cancer

Surgery is the only curative treatment for gastric (stomach) cancer. If the cancer is diagnosed early and limited to one part of the stomach, The tumor and only part of the stomach may be removed (partial or subtotal gastrectomy.) More often, the entire stomach is removed (total gastrectomy) along with the surrounding lymph nodes. When the entire stomach is removed, the esophagus is attached directly to the small intestine.

A gastrectomy is performed under general anesthesia. Once the patient is anesthetized, a urinary catheter is usually inserted to monitor urine output. A thin nasogastric tube is inserted into the nose, through the esophagus, and into the stomach. The abdomen is cleansed with an antiseptic solution. The surgeon makes a large incision from just below the breastbone down to the navel. The surgeon then removes all or part of the stomach and attaches connects either the remaining piece of stomach or the esophagus to the small intestine.

Gastrectomy for gastric cancer is almost always done using the traditional open surgery technique, which requires a wide incision to open the abdomen. However, some surgeons use a laparoscopic technique that requires only a small incision. The laparoscope is connected to a tiny video camera that relays a picture of the abdomen to a monitor to guide the surgeon who then operates through this incision.

KEY TERMS

Adenocarcinoma— A form of cancer that involves cells from the lining of the walls of many different organs of the body.

Antrectomy— A surgical procedure for ulcer disease in which the antrum, a portion of the stomach, is removed.

Biopsy— Surgical removal of a small piece of tissue so that it can be examined under the microscope for malignancy (cancer).

Laparoscopy— The examination of the inside of the abdomen through a lighted tube (endoscope) inserted through a small incision, sometimes accompanied by surgery.

Lymphoma— Malignant tumor of lymphoblasts derived from B lymphocytes, a type of white blood cell.

The potential benefits of laparoscopic surgery include less postoperative pain, decreased hospitalization, and earlier return to normal activities. The use of laparoscopic gastrectomy is limited, however. Only patients with early-stage gastric cancers or those whose surgery is intended only as palliative treatment (pain and symptomatic relief rather than cure) are considered for this minimally invasive technique.

Gastrectomy for ulcers

Gastrectomy is also used occasionally in the treatment of severe peptic ulcer disease or its complications. While the vast majority of peptic ulcers (gastric ulcers in the stomach or duodenal ulcers in the duodenum) are managed with medication, partial gastrectomy is sometimes required for peptic ulcer patients who have complications. These include patients who do not respond satisfactorily to medical therapy, those who develop a bleeding or perforated ulcer, and those who develop pyloric obstruction (a blockage to the exit from the stomach). The surgical procedure for severe ulcer disease is also called an antrectomy. An antrectomy is a limited form of gastrectomy in which the antrum, or lower portion of the stomach that produces digestive juices, is removed.

Diagnosis/Preparation

Before undergoing gastrectomy, patients require a variety of tests such as x rays, computed tomography (CT) scans, ultrasonography, or endoscopic biopsies (microscopic examination of tissue) to confirm the diagnosis and localize the tumor or ulcer. Laparoscopy and tissue biopsy may be used to diagnose a malignancy or to determine the extent of a tumor that is already diagnosed. When a tumor is strongly suspected, laparoscopy is often performed immediately before the surgery to remove the tumor. This avoids the need to anesthetize the patient twice, and sometimes avoids the need for surgery completely if the tumor found through laparoscopy is deemed inoperable.

Aftercare

After gastrectomy surgery, patients are taken to the recovery unit and vital signs are closely monitored by the nursing staff until the anesthesia wears off. Patients commonly feel pain from the incision, and pain medication is prescribed to provide relief and is usually delivered intravenously (IV, directly into a vein). Upon waking from anesthesia, patients have an intravenous line, a urinary catheter, and a nasogastric tube in place. They cannot eat or drink immediately following surgery. In some cases, oxygen is delivered through a mask that fits over the mouth and nose. The nasogastric tube is attached to intermittent suction to keep what remains of the stomach empty.

If the whole stomach has been removed, the tube goes directly to the small intestine and remains in place until bowel function returns. This can take two to three days and is monitored by listening with a stethoscope for bowel sounds. When bowel sounds return, the patient can drink clear liquids. If the liquids are tolerated, the nasogastric tube is removed and the diet is gradually changed from liquids to soft foods, and then to more solid foods. Dietary adjustments may be necessary, as certain foods may now be difficult to digest. Overall, gastrectomy surgery usually requires a stay of 7–10 days in the hospital and recuperation time of at least several weeks.

Risks

Surgery for peptic ulcer is effective, but it may result in a variety of postoperative complications. Following gastrectomy surgery, as many as 30% of patients have significant symptoms. An operation called highly selective vagotomy, in which a nerve that stimulates the stomach is cut, is now preferred for ulcer management, as it is safer than gastrectomy.

After a gastrectomy, several abnormalities may develop that produce symptoms related to food intake. They happen largely because the stomach, which serves as a food reservoir, has been reduced in its capacity by the surgery. Other surgical procedures

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

A gastrectomy is performed by a board-certified surgeon trained in gastroenterology, the branch of medicine that deals with the diseases of the digestive tract. An anesthesiologist is responsible for administering anesthesia The operation is always performed in a hospital setting.

that often accompany gastrectomy for ulcer disease can also contribute to later symptoms. These other surgical procedures include vagotomy, which lessens acid production and slows stomach emptying, and pyloroplasty, which enlarges the opening between the stomach and small intestine to facilitate emptying of the stomach.

Some patients experience lightheadedness, heart palpitations (racing heart), sweating, nausea, and vomiting after a meal. These may be symptoms of dumping syndrome, as food is rapidly moved into the small intestine from the remaining stomach or directly from the esophagus. Dumping syndrome is treated by adjusting the diet and pattern of eating, for example, eating smaller, more frequent meals, and limiting liquids.

Patients who have abdominal bloating and pain after eating, followed frequently by nausea and vomiting, may have afferent loop syndrome, a serious condition that must be corrected surgically. Patients who have early satiety (feeling of fullness after eating), abdominal discomfort, and vomiting may have bile reflux gastritis (also called bilious vomiting), which is also surgically correctable. Many patients experience weight loss after gastrectomy.

Reactive hypoglycemia is a condition that results when blood sugar levels become too high after a meal, stimulating the release of insulin, occurring about two hours after eating. Should this occur after gastrectomy, changing to a high-protein diet and smaller meals is advised.

Ulcers recur in a small percentage of patients after partial gastrectomy for peptic ulcer. Recurrence is usually within the first few years after surgery. Further surgery is usually necessary.

Vitamin and mineral supplementation is necessary after gastrectomy to correct certain deficiencies, especially vitamin B_12, iron, and folate. Vitamin D and calcium are also needed to prevent and treat the bone

QUESTIONS TO ASK THE DOCTOR

• What happens on the day of surgery?
• What type of anesthesia will be used?
• How long will it take to recover from the surgery?
• When can I expect to return to work and/or resume normal activities?
• What are the risks associated with a gastrectomy?
• How many gastrectomies do you perform in a year?
• What is the rate of postsurgical complications among your patients?
• Will there be a scar?

problems that often occur. These include softening and bending of the bones, which can produce pain and osteoporosis, which is a loss of bone mass. According to one study, the risk for spinal fracture after gastrectomy may be as high as 50%.

Normal results

Overall, survival after gastrectomy for gastric cancer varies greatly by the stage of disease at the time of surgery. For early gastric cancer, the five-year survival rate is as high as 77%. For late-stage disease, the five-year survival rate is only 3%. The five-year survival rate for cancers in the lower stomach is better than for those found in the upper stomach, and the survival rate for gastric lymphoma is better than for gastric adenocarcinomas.

Most studies have shown that patients can have an acceptable quality of life after gastrectomy for a potentially curable gastric cancer. Many patients maintain a healthy appetite and eat a normal diet. Others lose weight and do not enjoy meals as much as before gastrectomy. Some studies show that patients who have total gastrectomies have more disease-related or treatment-related symptoms after surgery and poorer physical function than patients who have subtotal gastrectomies. There does not appear to be much difference, however, in emotional status or social activity level between patients who have undergone total versus subtotal gastrectomies.

Morbidity and mortality rates

Depending on the extent of surgery, the risk for postoperative death after gastrectomy for gastric cancer has been reported as 1-3%, and the risk of nonfatal complications as 9–18%.

Resources

BOOKS

Beers, Mark H., Robert S. Porter, and Thomas V. Jones, eds. “Disorders of the Stomach and Duodenum.” In The Merck Manual, 18th ed. Whitehouse Station, NJ: Merck, 2007.

Feldman, Mark, et al., eds. “Stomach and Duodenum:Complications of Surgery for Peptic Ulcer Disease.” In Sleisenger’s and Fordtran’s Gastrointestinal and Liver Disease, 8th ed. Philadelphia: W. B. Saunders Co., 2006.

ORGANIZATIONS

American College of Gastroenterology. P.O. Box 342260 Bethesda, MD 20827-2260. (301) 263-9000. http://www.acg.gi.org (accessed March 23, 2008).

American Gastroenterological Association (AGA). 4930 Del Ray Avenue, Bethesda, MD 20814. (301) 654-2055. http://www.gastro.org (accessed March 23, 2008).

Caroline A. Helwick

Monique Laberge, PhD

Tish Davidson, AM

Gastrectomy

Definition

Gastrectomy is the surgical removal of all or part of the stomach.

Purpose

Gastrectomy is performed for several reasons, most commonly to remove a malignant tumor or to cure a perforated or bleeding stomach ulcer.

Description

Gastrectomy for cancer

Removal of the tumor, often with removal of surrounding lymph nodes, is the only curative treatment for various forms of gastric (stomach) cancer. For many patients, this entails removing not just the tumor but part of the stomach as well. The extent to which lymph nodes should also be removed is a subject of some debate, but some studies show additional survival benefit associated with removal of a greater number of lymph nodes.

Gastrectomy, either total or subtotal (also called partial), is the treatment of choice for gastric adenocarcinomas, primary gastric lymphomas (originating in the stomach), and the rare leiomyosarcomas (also called gastric sarcomas ). Adenocarcinomas are by far the most common form of stomach cancer and are less curable than the relatively uncommon lymphomas, for which gastrectomy offers good odds for survival.

After gastrectomy, the surgeon may "reconstruct" the altered portions of the digestive tract so that it continues to function. Several different surgical techniques are used, but, generally speaking, the surgeon attaches any remaining portion of the stomach to the small intestine.

Gastrectomy for gastric cancer is almost always done by the traditional "open" surgery technique, which requires a wide incision to open the abdomen. However, some surgeons use a laparoscopic technique that requires only a small incision. The laparoscope is connected to a tiny video camera that projects a picture of the abdominal contents onto a monitor for the surgeon's viewing. The stomach is operated on through this incision.

The potential benefits of laparoscopic surgery include less postoperative pain, decreased hospitalization, and earlier return to normal activities. The use of laparoscopic gastrectomy is limited, however. Only patients with early stage gastric cancers or those whose surgery is only intended for palliation—pain and symptomatic relief rather than cure—should be considered for this minimally invasive technique. It can only be performed by surgeons experienced in this type of surgery.

Gastrectomy for ulcers

Gastrectomy is also occasionally used in the treatment of severe peptic ulcer disease or its complications. While the vast majority of peptic ulcers (gastric ulcers in the stomach or duodenal ulcers in the duodenum) are managed with medication, partial gastrectomy is sometimes required for peptic ulcer patients who have complications. These include patients who do not respond satisfactorily to medical therapy, those who develop a bleeding or perforated ulcer, and those who develop pyloric obstruction, a blockage to the exit from the stomach.

The surgical procedure for severe ulcer disease is also called an antrectomy, a limited form of gastrectomy in which the antrum, a portion of the stomach, is removed. For duodenal ulcers, antrectomy may be combined with other surgical procedures that are aimed at reducing the secretion of gastric acid, which is associated with ulcer formation. This additional surgery is commonly a vagotomy, surgery on the vagus nerve that disables the acid-producing portion of the stomach.

Preparation

Before undergoing gastrectomy, patients may need a variety of tests, such as x rays, computed tomography scans (CT scans), ultrasonography, or endoscopic biopsies (microscopic examination of tissue), to assure the diagnosis and localize the tumor or ulcer. Laparoscopy may be done to diagnose a malignancy or to determine the extent of a tumor that is already diagnosed. When a tumor is strongly suspected, laparoscopy is often performed immediately before the surgery to remove the tumor; this avoids the need to anesthetize the patient twice and sometimes avoids the need for surgery altogether if the tumor found on laparoscopy is deemed inoperable.

Aftercare

It is important to follow any instructions that have been given for postoperative care. Major surgery usually requires a recuperation time of several weeks.

Risks

Surgery for peptic ulcer is effective, but it may result in a variety of postoperative complications. After gastrectomy, as many as 30% of patients have significant symptoms. An operation called highly selective vagotomy is now preferred for ulcer management, and is safer than gastrectomy.

After a gastrectomy, several abnormalities may develop that produce symptoms related to food intake. This happens largely because the stomach, which serves as a food reservoir, has been reduced in its capacity by the surgery. Other surgical procedures that often accompany gastrectomy for ulcer disease can also contribute to later symptoms: vagotomy, which lessens acid production and slows stomach emptying, and pyloroplasty, which enlarges the opening between the stomach and small intestine to facilitate emptying of the stomach.

Some patients experience light-headedness, heart palpitations or racing heart, sweating, and nausea and vomiting after a meal. These may be symptoms of "dumping syndrome," as food is rapidly "dumped" into the small intestine from the stomach. This is treated by adjusting the diet and pattern of eating, for example, eating smaller, more frequent meals, and limiting liquids.

Patients who have abdominal bloating and pain after eating, frequently followed by nausea and vomiting, may have what is called the afferent loop syndrome. This is treated by surgical correction. Patients who have early satiety (feeling of fullness after eating), abdominal discomfort, and vomiting may have bile reflux gastritis (also called bilious vomiting), which is also surgically correctable. Many patients also experience weight loss.

Reactive hypoglycemia is a condition that results when blood sugar becomes too high after a meal, stimulating the release of insulin, about two hours after eating. A high-protein diet and smaller meals are advised.

Ulcers recur in a small percentage of patients after surgery for peptic ulcer, usually in the first few years. Further surgery is usually necessary.

Vitamin and mineral supplementation is necessary after gastrectomy to correct certain deficiencies, especially vitamin B₁₂, iron, and folate. Vitamin D and calcium are also needed to prevent and treat the bone problems that often occur. These include softening and bending of the bones, which can produce pain, and osteoporosis, a loss of bone mass. According to one study, the risk for spinal fractures may be as high as 50% after gastrectomy.

Depending on the extent of surgery, the risk for post-operative death after gastrectomy for gastric cancer has been reported as 1-3% and the risk of non-fatal complications as 9-18%.

Normal results

Overall survival after gastrectomy for gastric cancer varies greatly by the stage of disease at the time of surgery. For early gastric cancer, the five-year survival rate is up to 80-90%; for late-stage disease, the prognosis is bad. For gastric adenocarcinomas that are amenable to gastrectomy, the five-year survival rate is 10-30%, depending on the location of the tumor. The prognosis for patients with gastric lymphoma is better, with five-year survival rates reported at 40-60%.

Most studies have shown that patients can have an acceptable quality of life after gastrectomy for a potentially curable gastric cancer. Many patients will maintain a healthy appetite and eat a normal diet. Others may lose weight and not enjoy meals as much. Some studies show that patients who have total gastrectomies have more disease-related or treatment-related symptoms after surgery and poorer physical function than patients who have subtotal gastrectomies. There does not appear to be much difference, however, in emotional status or social activity level between patients who have undergone total versus subtotal gastrectomies.

Resources

BOOKS

Feldman, Mark., et al., editors. "Stomach and Duodenum: Complications of Surgery for Peptic Ulcer Disease." In Steisenger & Fordtran's Gastrointestinal and Liver Disease. Philadelphia: W. B. Saunders Co., 1998.

KEY TERMS

Antrectomy— A surgical procedure for ulcer disease in which the antrum, a portion of the stomach, is removed.

Laparoscopy— The examination of the inside of the abdomen through a lighted tube, sometimes accompanied by surgery.