Gastrectomy — How It Works, Benefits & Recovery — Procedure Guide, Recovery & Risks | MyMedicPlus

Gastrectomy is the surgical removal of part or all of the stomach, performed by a specialist upper gastrointestinal or oncological surgeon. Partial (subtotal) gastrectomy removes the distal two-thirds of the stomach, preserving the cardia and gastro-oesophageal junction; total gastrectomy removes the entire stomach from the gastro-oesophageal junction to the pylorus. The procedure is predominantly performed for gastric (stomach) cancer — the fifth most common cancer worldwide, with over one million new cases annually — and also for gastrointestinal stromal tumours (GIST), refractory peptic ulcer disease with perforation or haemorrhage, and benign high-risk polyp syndromes. Sleeve gastrectomy, a distinct bariatric procedure, removes approximately 80% of the stomach longitudinally to restrict food intake without bowel rerouting. Gastrointestinal continuity after oncological gastrectomy is restored by Billroth II gastrojejunostomy (partial), Roux-en-Y oesophagojejunostomy (total), or Billroth I gastroduodenostomy (selected partial cases). Laparoscopic and robotic-assisted gastrectomy have largely replaced open surgery at high-volume centres in East Asia, achieving equivalent oncological clearance with faster recovery. D2 lymphadenectomy — dissection of the perigastric and regional lymph node stations — is the standard of care for resectable gastric cancer, and is associated with improved survival outcomes compared with D1 dissection in long-term randomised trial follow-up.

Gastrectomy is indicated for curative and palliative intent across several gastric pathologies. Gastric adenocarcinoma (Stages I–III) amenable to R0 resection is the primary indication; even Stage IV disease with distant metastasis may require palliative gastrectomy to control bleeding or obstruction. Gastrointestinal stromal tumours (GIST) larger than 2 cm or with high mitotic index require surgical resection, with imatinib neoadjuvant therapy used in locally advanced or borderline resectable cases. Peptic ulcer disease complicated by perforation not controlled by primary repair, massive haemorrhage refractory to endoscopic haemostasis, or gastric outlet obstruction from scarring may require partial gastrectomy. Fundal or diffuse gastric polyps with dysplasia or hereditary diffuse gastric cancer (CDH1 mutation carriers) warrant prophylactic total gastrectomy, as lifetime cancer risk approaches 80%. Contraindications to curative gastrectomy include non-resectable stage IV disease with disseminated peritoneal metastases, poor performance status (ECOG 3–4), severe cardiorespiratory comorbidity precluding general anaesthesia, and patient refusal after informed consent. Nutritional optimisation with oral supplementation or nasojejunal feeding for 1–2 weeks pre-operatively is recommended in malnourished patients (>10% weight loss) to reduce post-operative complications.

For oncological gastrectomy, the patient is positioned supine under general anaesthesia. Laparoscopic total gastrectomy begins with creation of a 12 mmHg CO2 pneumoperitoneum through a 10–12 mm umbilical camera port and placement of four additional working trocars in the upper abdomen. The greater omentum is mobilised off the transverse colon and the gastroepiploic vessels are divided. The left and right gastric arteries and short gastric vessels are sequentially divided using a vessel-sealing device at their origins, allowing en bloc removal of the stomach with the greater and lesser omentum attached. D2 lymphadenectomy includes systematic dissection of the hepatoduodenal ligament (station 12), coeliac axis (station 9), left gastric artery (station 7), common hepatic artery (station 8a), and splenic artery nodes (station 11p, 11d). The distal extent is divided at the proximal duodenum using a linear stapler; the proximal extent is divided at the gastro-oesophageal junction using an endoscopic linear stapler introduced through a 12 mm port. The specimen is placed in an extraction bag and removed through a 5–7 cm mini-laparotomy wound. Reconstruction: a 40 cm Roux limb of jejunum is fashioned and an oesophagojejunal anastomosis is created with a circular or linear stapler. The Roux limb is joined to the jejunum 40–60 cm distal to create the biliopancreatic limb. Operative time for laparoscopic total gastrectomy is 3–5 hours; partial gastrectomy takes 2–3 hours. A nasojejunal feeding tube is placed intra-operatively to allow early enteral nutrition.

Five-year survival after curative-intent gastrectomy with D2 lymphadenectomy: Stage IA approximately 90%, Stage IB 80%, Stage IIA 70%, Stage IIB 50%, Stage IIIA 40%, Stage IIIB–C 20–35%. Perioperative chemotherapy (FLOT regimen — docetaxel, oxaliplatin, leucovorin, 5-FU — 4 pre-operative and 4 post-operative cycles) significantly improves overall survival versus surgery alone in operable gastric and gastro-oesophageal junction cancers (FLOT4 trial: 5-year OS 45% vs 36%, median OS 50 vs 35 months). Laparoscopic gastrectomy for early gastric cancer achieves equivalent D2 lymph node harvest and 5-year recurrence-free survival compared to open surgery, with advantages of reduced intra-operative blood loss (100–200 mL vs 300–500 mL), shorter hospital stay (7–10 vs 10–14 days), and earlier return to chemotherapy. GIST resection with negative margins provides 5-year recurrence-free survival of 70–85% for completely resected primary tumours; adjuvant imatinib further reduces recurrence risk in high-risk cases. For patients with GIST and CDH1-mutation prophylactic gastrectomy, the procedure eliminates the near-certain risk of lethal diffuse-type gastric cancer.

Anastomotic leak at the oesophagojejunostomy (after total gastrectomy) is the most feared complication, occurring in 3–8% of cases and ranging from minor contained leaks managed conservatively to major leaks requiring re-operation, ICU admission, and prolonged hospitalisation. Duodenal stump leak (after partial gastrectomy with Billroth II reconstruction) occurs in 1–3%. Post-operative bleeding requiring re-exploration affects 1–3%. Intra-abdominal sepsis and abscess formation occur in 5–8% and are typically managed by CT-guided percutaneous drainage. Respiratory complications including pneumonia are common (5–10%) after major abdominal surgery and are reduced by early mobilisation and physiotherapy. Anastomotic stricture at the oesophagojejunostomy causing dysphagia occurs in 3–10% and is managed by endoscopic balloon dilation. Operative mortality for elective total gastrectomy in high-volume specialist centres is 1–3%; higher at lower-volume centres. Nutritional consequences of total gastrectomy include dumping syndrome (early: 20–40%; late: 10–20%), weight loss (average 15–20% of pre-operative body weight), vitamin B12 deficiency (universal — requiring 3-monthly intramuscular injections), iron deficiency anaemia, calcium and vitamin D deficiency, and protein malnutrition requiring long-term dietitian follow-up.

Enhanced recovery after surgery (ERAS) protocols are applied for gastrectomy: early oral fluids and clear diet on day 1–2, removal of nasogastric tube within 24 hours unless output is high, urinary catheter removal at 24–48 hours, and progressive mobilisation from day 1. The nasojejunal feeding tube placed intra-operatively provides enteral nutrition during the first 3–5 days while oral intake is established. Hospital stay ranges from 5–8 days for laparoscopic partial gastrectomy to 8–12 days for open total gastrectomy, with complications extending stay considerably. Pain management uses multimodal analgesia — thoracic epidural or intrathecal morphine, regular paracetamol and NSAIDs, opioids for breakthrough pain. Oral diet progresses from fluids to semi-solid to normal diet over 4–6 weeks post-operatively; small frequent meals (6–8 per day) replace normal meal patterns permanently after total gastrectomy. Vitamin B12 3-monthly intramuscular injections, daily iron supplementation, calcium, and vitamin D supplements are commenced before hospital discharge and continued lifelong. Return to desk-based work is at 6–8 weeks, manual work at 10–12 weeks. Adjuvant chemotherapy typically commences 6–8 weeks post-operatively; oncology follow-up with CT scans occurs at 6 months, 12 months, then annually for 5 years.