A gastrectomy is a major surgical procedure involving the partial or complete removal of the stomach, reserved for serious conditions affecting the upper digestive tract. The stomach stores food, mixes it with digestive juices, and controls its release into the small intestine. When only a portion is removed, the procedure is called a subtotal gastrectomy. This surgery aims to eliminate disease while preserving as much digestive function as possible. Following the procedure, adjustments to lifestyle and diet are necessary to ensure proper nutrient absorption and well-being.
Defining the Subtotal Gastrectomy
A subtotal gastrectomy involves removing the lower portion of the stomach, typically the distal two-thirds to four-fifths of the organ. This section includes the antrum, which grinds food and regulates its passage into the small intestine. The upper part, or gastric fundus, is left intact to act as a remnant food reservoir.
This procedure differs from a total gastrectomy, where the entire stomach is removed and the esophagus is connected directly to the small intestine. The goal of a subtotal resection is to remove diseased tissue, such as a tumor, while maintaining some digestive capacity. Depending on the extent of removal, it may be classified as an antrectomy (removing approximately 30% of the stomach) or a hemigastrectomy (removing about 50%).
Medical Conditions Requiring the Procedure
The primary reason for performing a subtotal gastrectomy is localized gastric cancer in the lower or middle sections of the stomach. The surgery is performed with curative intent, requiring the removal of the tumor along with surrounding lymph nodes to prevent disease spread. The precise location and size of the tumor dictate whether partial or total removal is necessary.
The procedure is also indicated for severe, benign conditions that have not responded to less invasive treatments. Complicated peptic ulcer disease, such as ulcers causing severe bleeding, perforation, or chronic obstruction, necessitates surgical intervention. Removing the ulcerated area resolves the immediate crisis and prevents recurrence. Certain large gastrointestinal stromal tumors (GISTs) or other benign tumors may also require subtotal gastrectomy if they are symptomatic or potentially cancerous.
Surgical Approaches and Reconstruction Methods
A subtotal gastrectomy can be performed using two main surgical approaches: open surgery (laparotomy) or a minimally invasive technique. Open surgery involves a single, large abdominal incision to access the stomach. Minimally invasive approaches, typically laparoscopic, use several small incisions for specialized instruments and a camera.
The laparoscopic technique often leads to a shorter hospital stay, less pain, and a quicker return to daily activities. However, the choice of approach depends on the patient’s overall health, the extent of the disease, and the surgeon’s expertise. Following stomach removal, the most functionally important step is the reconstruction of the digestive tract.
The remaining stomach remnant must be reconnected to the small intestine. The most common reconstruction is the Billroth I procedure (gastroduodenostomy), which joins the stomach directly to the duodenum. This method is considered the most physiological because it maintains the natural passage of food and digestive enzymes.
If a tension-free connection to the duodenum is not possible, or if complication risk is high, the Billroth II procedure (gastrojejunostomy) may be used. This method connects the stomach remnant to the jejunum, a more distal part of the small intestine, and the duodenum is sealed off. A third technique is the Roux-en-Y reconstruction, which separates the flow of food from the flow of digestive juices.
In a Roux-en-Y reconstruction, the remaining stomach connects to a limb of the jejunum. Bile and pancreatic secretions are routed into the intestine further down using a second connection. This configuration is chosen to reduce the risk of bile reflux into the stomach remnant, a complication associated with the Billroth II method. The surgeon selects the appropriate reconstruction based on the amount of stomach removed and the patient’s anatomy.
Managing Life After Stomach Removal
Life after a subtotal gastrectomy requires significant and permanent dietary adjustments because the stomach cannot hold the same volume of food or control its release effectively. The primary recommendation is to consume small, frequent meals, typically five to eight times per day, rather than three large ones. Patients must also chew food thoroughly to compensate for the stomach’s reduced ability to grind and mix contents.
A frequent complication following this surgery is dumping syndrome, resulting from the rapid emptying of highly concentrated food contents into the small intestine. This sudden influx causes a fluid shift into the intestine, leading to early dumping symptoms, which occur within 30 minutes of eating. These symptoms include abdominal cramping, nausea, diarrhea, and a rapid heart rate.
Late dumping syndrome occurs one to three hours after a meal, caused by the quick absorption of simple sugars leading to a blood sugar spike and crash. To manage both forms of dumping, patients should limit concentrated sweets and simple carbohydrates, which contribute to the osmotic shift. Eating a diet higher in protein and fat helps slow gastric emptying and stabilize blood sugar levels.
Liquids should be limited during meals, or consumed 30 minutes before or after eating, as they accelerate food transit from the stomach remnant. Lying down for 15 to 30 minutes after a meal can also help slow the emptying process. Long-term nutritional monitoring is necessary due to the altered absorption pathway.
The removal of the distal stomach can impair the absorption of certain micronutrients, leading to deficiencies. Iron and Vitamin B12 are of particular concern. The stomach produces intrinsic factor, necessary for B12 absorption, and stomach acid, which aids in iron release. Patients may develop anemia, requiring regular monitoring and lifelong supplementation, often including B12 injections.