Gastrectomy

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CHAPTER 8 Gastrectomy

BACKGROUND

The stomach may be divided into four anatomic regions: the cardia, fundus, body, and antrum. The stomach derives its blood supply from four main arterial trunks: the right and left gastric arteries along the lesser curvature and the right and left gastroepiploic arteries along the greater curvature. Additional blood supply is provided by the short gastric arteries (Fig. 8-1). Given this extensive collateral vascular network, the stomach may remain viable after ligation of multiple main feeding vessels. Venous and lymphatic drainage, in general, follows the arterial supply.

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Figure 8-1 Anatomy and arterial supply of the stomach.

(Adapted from Wein AJ [ed]: Campbell-Walsh Urology, 9th ed. Philadelphia, Saunders, 2007.)

INDICATIONS FOR GASTRECTOMY

The two most common indications for partial or total gastrectomy are malignancy and peptic ulcer disease (PUD).

I. Adenocarcinoma: Adenocarcinoma accounts for 95% of gastric malignancies and is the 14th most common cancer and the 8th leading cause of cancer-related death in the United States.

II. Other Gastric Malignancies

III. Peptic Ulcer Disease: PUD results from an imbalance between physiologic acid secretion and mucosal defense mechanisms and causes erosion of either the gastric or the duodenal wall. Advances in our understanding of the pathophysiology of PUD (specifically, the implications of H. pylori infection of the gastric mucosa) as well as the development of proton pump inhibitors for the management of acid hypersecretion have made elective surgery for the treatment of PUD uncommon. Initial treatment of PUD includes lifestyle modification (e.g., avoidance of tobacco, alcohol, and nonsteroidal anti-inflammatory drugs) and a pharmacologic regimen that includes an H2 receptor antagonist or proton pump inhibitor and antibiotic therapy for H. pylori infection.

TABLE 8-1 Johnson Classification of Gastric Ulcers

Johnson Classification Location Acid Hypersecretion
Type I Lesser curve No
Type II Lesser curve and duodenum Yes
Type III Prepyloric Yes
Type IV Proximal lesser curve near gastroesophageal junction No
image image image image

Figure 8-2 Gastric ulcers types I to IV. A, Type I. B, Type II. C, Type III. D, Type IV.

(From Townsend CM, Beauchamp RD, Evers BM, Mattox KL [eds]: Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice, 18th ed. Philadelphia, Saunders, 2008.)