Gastric Resection and Gastrectomy

Impact of diagnostics on surgical tactics

A thorough differential diagnosis is a key step before planning surgery. The surgeon must clearly differentiate a benign process from a malignant one, as well as inflammatory changes from tumor growth. It is precisely these data that dictate the radicality of the upcoming intervention:

• Malignant neoplasms (gastric cancer): the standard of treatment is gastrectomy, which implies total removal of the organ along with regional lymph outflow pathways.
• Benign pathologies (peptic ulcer disease): preference is given to gastric resection, i.e., excision of only the compromised fragment while preserving healthy tissues.

Gastrectomy: basic rule and strict indications

As a rule, gastrectomy is strongly recommended for the vast majority of gastric cancer cases. There are clinical situations in which any organ-preserving procedures are strictly prohibited. Such strict indications include:

1. Resectable gastric cancer with a specific pattern of infiltrative growth — type linitis plastica.
2. All undifferentiated forms of cancer.
3. Presence of hereditary diffuse gastric cancer syndrome in the patient.

In these situations, compromises are impossible, and the patient is indicated exclusively for complete removal of the stomach (grade of recommendation C, level of evidence 5).

Exceptions: when an organ-preserving surgery is possible

Despite the radicality of oncologic surgery, there are strict exceptions that allow a partial resection in the presence of a malignant process. The main condition for such a decision is the complete absence of severe dysplasia or cancer in situ stage in the part of the stomach planned for preservation.

An organ-preserving approach can be considered for the following locations and forms:

• Tumor lesion of the antrum of the stomach.
• Cancer in the gastroesophageal junction zone.
• Small-sized tumors localized in the fundus or cardia, provided they have an exophytic or mixed growth pattern.

Tactics after endoscopic interventions

A special group consists of patients who have already undergone endoscopic resection for adenoma or early gastric cancer. The main task at this stage is to prevent the development of a new (metachronous) tumor in the preserved organ.

To prevent metachronous gastric cancer, eradication of persistent infection is critically important (Grade of Recommendation B, Level of Evidence 1). Statistical data convincingly prove the effectiveness of this approach: compared to persisting infection, eradication therapy reliably reduces the incidence of metachronous cancer (relative risk RR 0.49; 95% confidence interval CI 0.34–0.70). The NNT (Number Needed to Treat) is 21, which means 21 patients need to be treated to prevent one case of metachronous cancer.

Class and exam questions

What else to study on this topic

• Clinical and morphological features of linitis plastica cancer.
• Hereditary diffuse gastric cancer syndrome: genetics and management tactics.
• Anatomical boundaries of the stomach parts when planning resection (antrum, cardia, fundus).
• Metachronous gastric cancer: pathogenesis of development after organ-preserving interventions.
• Criteria for severe dysplasia and cancer in situ at the resection margins.

Other topics in the "Additional Topics" section

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