The results of total gastrectomy in 47 patients with carcinoma of the stomach are reported. Extended total gastrectomy is recommended only if the growth cannot be removed by any other means. It should not be performed if the growth is not totally resectable. The operative mortality and postoperative results of total gastrectomy have improved to the extent that this operation for carcinoma of the stomach should be undertaken where indicated

Fox, Thomas A., Jr.

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Henry Ford Hospital Medical JournalVolume 18 | Number 1 Article 43-1970Total Gastrectomy for Carcinoma of the StomachThomas A. Fox Jr.Follow this and additional works at: https://scholarlycommons.henryford.com/hfhmedjournalPart of the Life Sciences Commons, Medical Specialties Commons, and the Public HealthCommonsThis Article is brought to you for free and open access by Henry Ford Health System Scholarly Commons. It has been accepted for inclusion in HenryFord Hospital Medical Journal by an authorized editor of Henry Ford Health System Scholarly Commons.Recommended CitationFox, Thomas A. Jr. (1970) "Total Gastrectomy for Carcinoma of the Stomach," Henry Ford Hospital Medical Journal : Vol. 18 : No. 1 ,21-26.Available at: https://scholarlycommons.henryford.com/hfhmedjournal/vol18/iss1/4Henry Ford Hosp. Med. Journal Vol. 18, No. 1, 1970 Total Gastrectomy for Carcinoma of the Stomach Thomas A. Fox, Jr., M.D.* The results of total gastrectomy in 47 patients with carcinoma of the stomach are reported. Extended total gastrectomy is recommended only if the growth cannot be removed by any other means. It should not be performed if the growth is not totally resectable. The operative mortality and postoperative results of total gastrectomy have improved to the extent that this operation for carcinoma of the stomach should be undertaken where indicated. Although the incidence of cancer of the stomach is decreasing in the United States, there are approximately 20,000 new cases developing each year.^  The proportion of incurable cases seen in recent years has remained fairly con-stant, indicating that early diagnosis has not advanced materially. The ques-tion then arises of whether a more radi-cal resection such as extended total gastrectomy would lead to a more favorable outcome. In this context, ex-tended total gastrectomy has been given consideration. Indications The limits of carcinoma of the stomach can be judged only very un-certainly by palpation and visual in-spection. The invisible intramural spread of the carcinoma is likely to overlap the gross tumor boundary by four to five centimeters. Histological study of patients dying after apparent curative resection has shown that 50% have recurrences in the gastric stump and 22% have malig-*General Surgery Division V I nant involvement of the perigastric lymph nodes.2 In 40% of cases of ex-tensive carcinoma and carcinoma in-volving the proximal part of the stom-ach, and in 30% of cases of carcinoma involving the distal part, this spread occurs to the lymph nodes along the tail of the pancreas and in the region of the spleen.^  In these situations, extended total gastrectomy offers definite advantages over the conventional subtotal gastrec-tomy. The scope of the operative field is as shown in Figure 1. The entire stomach and first portion of the duo-denum, the gastrohepatic and gastro-colic omenta, the spleen, and the body and tail of the pancreas are included. There are serious disadvantages in that the operative mortality after total gastrectomy is appreciably higher, and disturbances of digestion more severe. Total gastrectomy should never be-come a routine procedure for every case of carcinoma of the stomach. Rather, it is indicated in all cases of diffuse infiltrating growth involving a large part of the stomach, in all tumors of the cardia and fundus, and in all those tumors of the body which, be-21 Fox SCOPE of the OPERATIVE^ FIELD in EXTENDED TOTAL GASTRECTOMY. Figure 1 The scope of the operative field in extended total gastrectomy. The entire stomach and first portion of the duodenum, the gastrohepatic and gastrocolic omenta, the spleen and the body and tail of the pancreas are included. cause of their extent and site, can be expected to be invading the region of the left gastric artery, the tail of the pancreas and the spleen. With involve-ment of the antrum, a distal four-fifths resection is usually favored. Contraindications Total gastrectomy is contraindicated when (1) the surgeon is able to estab-lish that the operation will not rid his patient of cancer tissue; (2) in car-cinomatous peritonitis or extensive lymph node metastases which cannot be resected (e.g. in the vicinity of the superior mesenteric artery or the head of the pancreas), and (3) in the pres-ence of distant metastases. It should be discouraged as a pallia-tive measure, since it would only bur-den an already weakened and cachec-tic patient with a deficient digestion and make him less likely to survive early post-operative complications. Total gastrectomy always demands a careful decision as to whether the patient is equal to the operation. Ad-vanced age and severe preoperative weight loss are hazardous, according to Hegemann and Gall,-* who reported an operative mortality of 62.1% for patients over 65 years of age. 22 Total Gastrectomy for Carcinoma of the Stomach Material and Method This report consists of 47 patients (30 males and 17 females) who under-went total gastrectomy for carcinoma of the stomach during the period 1953-1967. Age distribution is shown in Figure 2. Of these, 24 operations were per-formed through an abdominal ap-proach, 21 through a thoraco-abdom-inal approach, and two through a thoracic approach. In addition to the stomach, the spleen was resected in 42 patients, the distal pancreas in 18, and portions of the transverse colon in six. In all cases, most of the greater omen-tum was removed. Reconstruction of the gastrointes-tinal tract was carried out by a variety of procedures (Table I ) . Results Total gastrectomy for carcinoma of the stomach carries a significant mor-tality.- '^^  In our group of 47 patients, nine died, giving an operative mortality Table I TOTAL GASTRECTOMY FOR CARCINOMA OF STOMACH Type of Reconstruction Jejunal interposition 12 Jejunal interposition witti Figure of 9 Esoptiago-duodenostomy Loop esophago-jejunostomy witti entero-enterostomy Loop esoptiago-jejunostomy without entero-enterostomy lleo-cecal interposition Total 1 1 47 of 19%. Many of these resections were obviously palliative. The principal cause of death (Table Table I I TOTAL GASTRECTOMY FOR CARCINOMA OF STOMACH Operative Mortality Cause of Death Anastomotic leak Post-operative hemorrhage Multiple intra-abdominal abscesses Suspected pulmonary embolus (no autopsy) Total Per cent operative mortality = 9/47 x 100 = 19% Number of Cases 15-1 S 10-.*— o Q. "5 5-6 AGE DISTRIBUTION OF PATIENTS WITH CARCINOMA OF THE STOMACH (one patient - no age recorded) 5 6 7 8 AGE (Decades) Figure 2 23 Fox I I ) was leaking or rupture of the anastomotic suture lines. The operative morbidity is rather high in these pa-tients, as shown by length of hospitali-zation (Fig 3). Length of survival is shown in Figure 4. Al l deaths were considered to be due to the carcinoma. Of the 47 patients, 33 had lymph node metastases, 5 had no lymph node metastases, and in 9 patients there was 6-1 cn c: 4-Q_ o 2H 0-minimunn = 16 days nnaximum = 88 days average = 44 days (0) (0) 16-20 I 26-30 I 36-40 j 46-50 | 56-60 | 66-70 | 76-80 j 86-90 21-25 31-35 41-45 51-55 61-65 71-75 81-85 Length of Hospitalization (Days) Figure 3 Length of stay in hospital following total gastrectomy. 24 Total Gastrectomy for Carcinoma of the Stomach no record as to the involvement of the lymph nodes. Both the five-year sur-vivor and the patient who has survived for 41 months had lymph node involve-ment. Discussion The ideal operation for carcinoma of the stomach should remove the pri-mary tumor widely through the healthy tissue with block dissection of the regional lymph glands. This result is more nearly accomplished by the ex-tended total gastrectomy which in-volves resection of the stomach, omen-tum, spleen, and distal pancreas. Ap-plication may be limited because of close proximity to vital structures like the hepatic and superior mesenteric arteries and the biliary passages. The mortality from this operation has gradually fallen to a reasonable 100-± 80 > a: cn < 60' 4 0 -2 0 -level. Among the best results are those of ReMine et al who report a mortality of 15% and a five-year survival of 10%.-'' Our five-year survival rate is 3 %. Still, these figures indicate that some patients can be cured by aggres-sive surgery. The type of gastrointestinal recon-struction has been a matter of some debate. Some of the more common types are shown in Figure 5. ReMine^ feels that the most satis-factory method is an end-to-side esoph-agojejunostomy with a diverting side to side entero-enterostomy well below the esophagojejunostomy. This is the type of reconstruction presently being employed by most surgeons at this hos-pital. Regardless of the type of recon-struction, most patients experience re-flux esophagitis. There is no known anastomotic technique to prevent it. * TWO PATIENTS LOST TO FOLLOW-UP a CONSIDERED TO HAVE DIED OF DISEASE * * ONE PATIENT LIVING a WELL AFTER 41 MOS. 1 ^ 6 12 18 —1 1 1 1 1 1 1 24 30 36 42 48 5 4 60 TIME IN MONTHS Figure 4 Five-year survival of patients undergoing total gastrectomy for carcinoma of the stomach. 25 Fox LOOP E S O P H A G O -JEJUNOSTOMY WITH ENTERO-ENTEROSTOMY (6 Patients) ROUX-Y ESOPHAGO-JEJUNOSTOMY ( 0 Patients) JEJUNAL INTER-POSITION (22 Patients) ESOPHAGO - DUODENOSTOMY (12 Patients) Figure 5 Most common types of gastrointestinal reconstruction following total gastrectomy. REFERENCES 1. 1968 Cancer Facts and Figures: New York, American Cancer Society. 2. McNeer, G., et al: A more thorough operation for gastric cancer. Anatomical basis and description of technique. Cancer 4:957-67, Sept 1951. 3. ReMine, W. H., and Priestley, J.T.: Trends in prognosis and surgical treatment of cancer of the stomach. Ann Surg 163:736-45, May 1966. 4. Hegemann, G., and Gall, F.: The management of carcinoma of the stomach by total gastrectomy. German Med Monthly 13:153-9, Apr 1968. 5. Allison, P.R.: Radical total gastrectomy for carcinoma of the stomach. Lancet 1:1014-6 I I May 1963. 26 

Total Gastrectomy for Carcinoma of the Stomach

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Total Gastrectomy for Carcinoma of the Stomach

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