Total Gastrectomy for Stomach Cancer

If you have stomach (or gastric) cancer and are discussing treatment options with your cancer care team, you may have heard about a type of surgery called a total gastrectomy. All of this new information about gastrectomies can leave you feeling overwhelmed and intimidated if you don’t know what to expect. Because of this, understanding how a total gastrectomy works is very important. It can help you prepare yourself for this major procedure while making the whole experience a little less unnerving.

Often performed as part of gastric cancer treatment, a total gastrectomy is a surgical procedure where the entire stomach is removed. It is typically used to treat and cure cancers that have spread widely in the stomach as well as proximal gastric cancers, which affect the upper part of the stomach.

A total gastrectomy is also recommended for people with a rare inherited genetic syndrome called hereditary diffuse gastric cancer (HDGC). This condition is associated with an increased risk of developing diffuse type adenocarcinomas, an invasive form of gastric cancer that is impossible to detect in the early treatable stages. Therefore, if you have HDGC, your doctors will likely encourage you to have a prophylactic (preventative) total gastrectomy as it is the only proven way to effectively prevent diffuse gastric cancer.

Your surgeons will first remove the entire stomach and the omentum, an apron-like layer of fatty tissue covering the stomach and intestines. They will then remove nearby lymph nodes through a procedure known as a lymph node dissection or lymphadenectomy. The aim of this is to reduce the risk of your gastric cancer coming back in the future, seeing that some of these lymph nodes could be cancerous. Moreover, your doctors can examine these lymph nodes to determine more accurately how far your cancer has spread. This may inform their decisions regarding treatment options.

In the United States, it is recommended that at least 16 lymph nodes be removed when a gastrectomy is performed. This is known as a D1 lymphadenectomy.

If the spleen and parts of other surrounding organs, such as the esophagus and small intestine, are affected by the cancer, they may also be removed.

After the aforementioned parts are removed, the gastrointestinal tract needs to be reconstructed so that food can continue to move through the digestive system. The standard procedure for this is a Roux-en-Y reconstruction with a jejunal pouch.

In this reconstruction technique, a cut is made across the jejunum — the middle part of the small intestine — to create two distinct segments: the afferent limb and the Roux limb. The afferent limb consists of the first part of the small intestine (duodenum) and the uppermost (proximal) portion of the jejunum. The Roux limb comprises the rest of the jejunum followed by the rest of the small intestine.

The Roux limb is brought up to the remaining part of the esophagus. Sometimes the jejunum is folded back onto itself to construct a 10 cm-long jejunal pouch. Not only does this pouch serve as a reservoir for swallowed food, but its creation can also lower the risk of postoperative complications and improve your quality of life. The Roux limb is then joined to the remaining part of the esophagus in what is called an esophagojejunostomy. After the proximal jejunum on the afferent limb is connected to the distal part of the Roux limb to create a jejunojejunostomy, reconstruction is complete.

If you experience preoperative weight loss or other risk factors associated with a complicated or delayed recovery, your surgeons may consider placing a jejunal feeding tube. The tube is inserted into your small intestine, through which nutrients and medications are delivered in the postoperative period. While it is not routinely recommended, the placement of this feeding tube ensures that you receive adequate nutrition during your recovery.

Many people think of the stomach as an integral part of the body, but it is possible to live without it. If you’ve had a gastrectomy to remove the organ, life without a stomach will take some getting used to.

You will likely need to stay in the hospital for several days following the procedure, where you receive nutrition intravenously or through a stomach tube. While recovering at home, you may experience decreased ability to eat, unintentional weight loss or other postoperative complications. Learning to live with these changes could mean making certain lifestyle adjustments, such as avoiding high-fiber foods and taking smaller but more frequent meals.

> Find out more about coping with post-gastrectomy recovery

Transitioning to life after a gastrectomy and without a stomach may seem very daunting, but undergoing this major surgery can significantly lower the risk of cancer coming back and improve your chances of survival after gastric cancer.

“You don’t need a stomach to live a normal life.”

– Dr. Anton Bilchik, Chief of General Surgery and Director of Gastrointestinal and Hepatobiliary Program and Research at Saint John’s Cancer Institute