Gastrectomy is a surgical procedure performed to remove some or all of the patient’s stomach. Three main kinds of gastrectomy exist. First, partial gastrectomy. If the surgeons remove only part of the stomach, it is called a partial gastrectomy. Second, total gastrectomy. If the surgeons remove the entire stomach, it is called a total gastrectomy. Third, sleeve gastrectomy. If the surgeons remove only the left side of the stomach, it is called a sleeve gastrectomy. Partial and total gastrectomies are used to prevent and treat stomach cancer. In contrast, sleeve gastrectomies are used for weight loss. This article focuses on total gastrectomies. Total gastrectomies are the recommended course of action for individuals who have a CDH1 mutation and are healthy enough for surgery.
How is a total gastrectomy performed?
A total gastrectomy involves detaching the stomach from the esophagus and small intestine with a Roux-en-Y reconstruction. In layperson terms, here is what happens. Note, however, the following description is not necessarily how to perform the surgery. For instance, the list of steps is incomplete and oversimplified. Also, the steps are not necessarily in the right order. Rather, the following description is meant to be a simple way to conceptualize how the surgeons reorganize the gut.
First, the stomach is detached from both the esophagus and small intestine (specifically, the duodenum portion of the small intestine). Second, the surgeons find a location on the small intestine between the duodenum and jejunum. Third, at that location, the surgeons separate the small intestine between the duodenum and jejunum. Fourth, the surgeons reposition the small intestine so that the jejunum is near the esophagus. Fifth, the jejunum-portion of that separation is attached to the esophagus. This connection is sometimes called the oesophago-jejunal anastomosis. Sixth, the duodenum-portion of the separated portion of small intestine is re-attached to the small intestine well below the oesophago-jejunal anastomosis. This is sometimes called the jejunojejunal anastomosis or the entero-enterostomy.
At the opposite end of the jejunojejunal anastomosis along the strip of small intestine is the duodenal stump. Between the end of the duodenal stump and the entero-enterostomy, the liver, gallbladder, and pancreas empty into the small intestine.
Gastrectomy: What are some specifics that I should know?
In 2015, a team of nearly fifty of the most informed CDH1 healthcare professionals from all around the world published guidelines for the clinical care of CDH1 mutation carriers. The guidelines’ title is “Hereditary diffuse gastric cancer: updated clinical guidelines with an emphasis on germline CDH1 mutation carriers.” The guidelines explain, among other things, the operation details for total gastrectomy. They make several specific recommendations about the surgery.
Center of Expertise
One recommendation is to have a “center of expertise” perform your total gastrectomy. For instance, the 2015 guidelines recommend “prophylactic total gastrectomy at a centre of expertise.” A paper published by U.S. doctors agrees. Specifically, it says: “total prophylactic gastrectomy, performed between the ages of 18 and 40 at a high-volume cancer center with low perioperative mortality rates, is advised in CDH1 mutation carriers fulfilling the clinical criteria for HDGC.” For a third example, Dutch researchers advise similarly: “Patients with suspected high risk for hereditary diffuse gastric cancer should be cared for in a multidisciplinary centre for hereditary tumour diseases.”
What is a center of expertise? It may not be clearly defined. However, at least one paper reports that the learning curve for total gastrectomy is 23 operations. Others may tell you the requisite number of operations is more like 40 or 3-4 per month sustained over several years.
To help you select a surgeon, No Stomach for Cancer has a list of surgeons who are experienced in performing prophylactic total gastrectomies for CDH1 carriers. High on our list, based on personal experience, are the University of Chicago and the National Institutes of Health. Both have great teams of passionate doctors who are experienced with CDH1 mutation carriers. Plus, both teams are at the forefront of research and development for CDH1 mutation carriers. Furthermore, the NIH is conducting a clinical trial for CDH1 mutation carriers. Therefore, your care will be free of charge.
Regardless, many great options exist. Be sure your CDH1 team knows the unique challenges diffuse cancers present. Like, for instance, in surveillance, surgery, and pathology. Here’s an example. An experienced gastroenterologist will know the specific technique used for surveillance, which is not a technique all gastroenterologists will already know and be experienced with. Choosing a surgeon experienced with total gastrectomy surgery will increase the odds that life after it will be normal.
Moreover, a surgeon experienced with diffuse gastric cancers will know the proper method for resecting lymph nodes and the best length of small intestine between your two new hookups, which is not necessarily something every surgeon already knows and has experience with.
Furthermore, an experienced pathologist will know how to distinguish malignant cells from those that appear similar but are benign. They will also know to examine the entire stomach tissue, not just enough to find one cancer cell.
Finally, you should also consider where your support system is. You may have to find the right balance between where home is and where the center of expertise is.
Open vs Minimally Invasive
One of the most-asked questions by patients exploring total gastrectomy is whether to have the surgery performed open, laparoscopically, or robotically. An open surgery is where the surgeon creates a large abdominal incision. This open technique allows the surgeon access to the patient’s gut with her hands. It also allows her to see the gut with her eyes.
Laparoscopic and robotic surgery, in contrast, are minimally invasive procedures. Rather than make a large abdominal incision, the surgeon makes several small incisions. Some are so small that only her instruments can enter. However, at least one will be large enough through which to remove the stomach. Instead of manipulating the patient’s gut with her hands, the surgeon uses instruments designed to mimic use of her hands. Instead of seeing the gut with her eyes, the surgeon will view the gut using a specialized camera.
Advantages of minimally invasive techniques are less blood loss, less post-surgery complications, less scar tissue, and potentially a quicker recovery time. Perhaps this is due to less surgical trauma. Plus, the surgeon can see a magnified view of the gut and move with more precision.
In 2015, Dutch researchers commented on some of the differences between minimally invasive techniques versus open. “Compared to open total gastrectomy for gastric cancer, laparoscopic total gastrectomy showed less blood loss, fewer postoperative complications, and shorter hospital admission time as well in this series as in literature.”
“A recent systematic review indicated that an open procedure is associated with a higher inflammatory response . . . compared to a laparoscopic procedure.”
A downside of minimally invasive techniques is that surgery may take longer. Plus, if your surgeon is not appropriately experienced performing minimally invasive techniques, the risk of something going wrong during surgery is significant. The Dutch researchers say: “Unlike laparoscopic distal gastrectomy, laparoscopic total gastrectomy is still not widely accepted as first choice of treatment. This is probably a reflection of laparoscopic total gastrectomy being a technically more demanding procedure than laparoscopic distal gastrectomy with a long learning curve.”
The 2015 guidelines recommend that a surgeon perform the technique that she is most familiar with. Some of the reasoning in support is that: “conclusive evidence for the superiority of [the minimally invasive techniques] is still lacking.”
Reduce Risk of Biliary Reflux
The 2015 guidelines recommend that “the jejunojejunal anastomosis is at least 50 cm distal to the oesophagogastric anastomosis.” In other words, the strip of small intestine between the two new connections should be at least 50 cm. The reason: “to reduce the risk of biliary reflux.”
Confirm No Remaining Stomach Tissue
When the surgeons detach the stomach, they need to ensure that they removed all the stomach tissue. When doctors say it, it sounds like this: “The proximal resection line must be across the distal oesophagus containing squamous epithelium to ensure that no gastric cardiac mucosa is left behind.”
The reason the surgeons are scrupulous about removing all the stomach tissue is because any stomach tissue remaining in the body could potentially develop into stomach cancer. This would mean the total gastrectomy did not serve its ultimate purpose.
Therefore, surgeons should confirm during surgery that all stomach tissue is removed. The 2015 guidelines say that absence of stomach tissue can be confirmed using a technique known as “frozen section” or by examining the resection specimen on the operating table. Also, the surgeon can use an on-table endoscopy to assist during surgery by marking the appropriate locations for detaching the stomach.
During surgery, the surgeon should examine the lymph nodes to see whether the cancer has spread from the stomach. According to the 2015 guidelines, not everyone agrees upon the same lymph node dissection strategy: “The optimal extent of lymph node dissection (LND) in prophylactic gastrectomy is controversial.” Despite the controversy, the authors have a recommendation: “Because a preoperative gastroduodenoscopy cannot exclude the presence of T1b lesions with their higher risk of metastases during the operation, a D1 LND (with the inclusion of lymph node stations 1–7) is reasonable.”
In layperson terms, the surgeon should remove at least some of the lymph nodes to make sure that early cancer cells have not spread. However, the surgeon does not need to remove all nearby lymph nodes.
The authors share some of their reasoning. First, many patients with cancer cells in their earliest stage (pT1a) should have no cancer cells in the lymph nodes: “Lymph node metastases are not reported in asymptomatic CDH1 mutation carriers with negative preoperative surveillance biopsies or small foci of pT1a intramucosal carcinoma.”
Second, however, some other patients with early-stage cancer (early stage, yes, but also more advanced than the previously mentioned group), are at risk of the cancer having already spread to the lymph nodes. As reported by the 2015 guidelines:
“Among patients with early-stage intestinal adenocarcinoma of the stomach, the frequency of lymph node metastasis in patients with early intramucosal (pT1a) tumours is 2–5%, and up to 6% in the undifferentiated or diffuse types.”
“In pT1b tumours, with invasion of the submucosal layer, lymph node metastases are found in 17–28%, increasing with the depth of submucosal invasion.”
Therefore, with these statistics in mind, the authors of the 2015 guidelines recommend that some lymph node resection is reasonable, even in patients demonstrating no signs or symptoms of diffuse gastric cancer.
Pouch vs No Pouch
Finally, some surgeons recommend forming a pouch near the oesophago-jejunal anastomosis (i.e., the connection between the esophagus and small intestine). In contrast, other surgeons do not recommend a pouch.
The 2015 guidelines report that a pouch “may improve eating for the first year after surgery.” However, it also reports that no studies have definitively proven that a pouch is better than no pouch: “prospective trials comparing pouch to straight Roux-en-Y reconstruction have not convincingly demonstrated significant long-term benefits.” Accordingly, the 2015 guidelines recommend that a surgeon should “use the reconstruction they are most familiar with.”
Gastrectomy: Vagus Nerve Preservation
One consideration not explicitly addressed in the 2015 guidelines is whether to preserve the vagus nerve during total gastrectomy surgery in patients with early stage cancer. In 2016, however, Korean researchers considered this exact issue. Essentially, the Korean researchers wanted to know whether keeping the vagus nerve intact during surgery would result in an improved quality of life for patients when compared to the quality of life for patients who underwent conventional total gastrectomy surgery.
In the study, the researchers enrolled 163 patients with early gastric cancer. Of those, 85 patients underwent total gastrectomy with their vagus nerve intact. The other 78 patients underwent conventional total gastrectomy.
The patients with their vagus nerve intact experienced a somewhat better quality of life compared to the others. Indeed, the researchers reported less diarrhea at 3 months and 12 months post surgery for the intact vagus nerve group. Also, the researchers reported less appetite loss at 12 months for the intact vagus nerve group.
However, at 3 months after surgery, both groups reported fatigue, anxiety, eating challenges, and body image deterioration. Though both groups were back to baseline around 1 year after surgery. Also, no significant differences existed between the groups in terms of cancer recurrence and death within 5 years of surgery.
The Korean researchers concluded that keeping the vagus nerve intact during total gastrectomy may improve quality of life. In addition, at least one other paper confirms that it is possible to preserve the posterior vagus nerve during prophylactic total gastrectomy. Therefore, to summarize, keeping the vagus nerve intact during prophylactic total gastrectomy is possible and may improve quality of life. However, the relative improvements in quality of life when compared to conventional total gastrectomy patients are limited in terms of types of improvements and duration of improvement.