Gastrectomy (Partial & Total)
What the Examiner Expects
Partial (distal/subtotal) or total resection of the stomach, most commonly performed for gastric adenocarcinoma, refractory peptic ulcer disease, or GIST tumors. For cancer, the examiner expects you to complete preoperative staging (EGD with biopsy, CT chest/abdomen/pelvis, diagnostic laparoscopy with peritoneal washings to rule out occult peritoneal disease), determine if neoadjuvant chemotherapy is indicated (FLOT regimen for T3+ or N+ disease), and describe the operative approach. Distal gastrectomy for antral tumors requires a 4–6 cm gross proximal margin with D2 lymphadenectomy. Total gastrectomy is performed for proximal, diffuse, or large tumors. Reconstruction after total gastrectomy is a Roux-en-Y esophagojejunostomy with a 40–60 cm Roux limb.
Key Examiner Focus Points
- Distal: adequate 4–6 cm proximal margin; Billroth I (gastroduodenostomy) vs Billroth II (gastrojejunostomy) vs Roux-en-Y reconstruction
- Total: en bloc resection with D2 lymphadenectomy for cancer; Roux-en-Y esophagojejunostomy reconstruction
- Minimum 15 lymph nodes for adequate staging
- Understand postgastrectomy syndromes: dumping, afferent loop, alkaline reflux gastritis, marginal ulcer
- Neoadjuvant chemo (FLOT regimen) for locally advanced gastric cancer
Common Curveballs
Diagnostic laparoscopy reveals positive peritoneal washings but no visible carcinomatosis
This is stage IV disease (M1). Gastrectomy is NOT indicated. Treat with systemic chemotherapy. Positive washings confer the same prognosis as gross peritoneal disease.
Patient develops early satiety, cramping, diarrhea, and diaphoresis after eating — 3 weeks post distal gastrectomy
Dumping syndrome. Early dumping (within 30 minutes) is due to rapid osmotic load. Manage with dietary modification: small frequent meals, avoid simple carbohydrates, separate liquids from solids. Octreotide for refractory cases.
Frozen section of the proximal margin comes back positive
Re-resect to achieve a negative margin. If you cannot achieve negative margins with subtotal gastrectomy, convert to total gastrectomy. A positive margin is unacceptable — this is a critical error that will result in a failing score.
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