Diagnosis of Total Gastrectomy

Total gastrectomy is a major surgical procedure involving the complete removal of the stomach, typically performed to treat advanced stomach cancer or other severe gastric conditions. Given its complexity and impact on digestion, diagnosing whether a patient requires total gastrectomy is a crucial and detailed process.

Before surgery is even considered, doctors need to confirm that this extensive operation is absolutely necessary. This involves a thorough evaluation of symptoms, clinical history, laboratory tests, endoscopic examinations, imaging scans, biopsies, and sometimes even genetic testing. A misdiagnosis or premature recommendation for gastrectomy can lead to unnecessary complications, while timely and accurate diagnosis can significantly improve a patient’s quality of life and survival outcomes.

What is Total Gastrectomy?

Total gastrectomy is a surgical intervention in which the entire stomach is removed. Once the stomach is removed, the esophagus is connected directly to the small intestine (usually the jejunum) to maintain the digestive tract’s continuity. This surgery is most commonly recommended for patients with :-

1. Stomach (gastric) cancer, especially in advanced or widespread cases

2. Genetic risk of gastric cancer (e.g., CDH1 mutation)

3. Severe peptic ulcer disease not responding to treatment

4. Certain types of gastric polyps or tumors

Because of its life altering effects on digestion and nutrition, total gastrectomy is considered only after a thorough diagnostic evaluation confirms its necessity.

Diagnosis of Total Gastrectomy

1. Initial Clinical Evaluation :- The first step in the diagnosis process begins with a clinical assessment. A physician will conduct a detailed review of the patient’s symptoms, medical history, and family history. Common symptoms that may lead a doctor to suspect a serious gastric condition include :-

   • Persistent abdominal pain

   • Unexplained weight loss

   • Difficulty swallowing

   • Frequent nausea and vomiting

   • Gastrointestinal bleeding or black stools

   • Chronic indigestion or bloating

   These symptoms may not always indicate the need for a gastrectomy, but they often warrant further investigation.

2. Physical Examination and Laboratory Tests :- A physical exam is conducted to assess the patient’s overall health, abdominal tenderness, and signs of nutritional deficiencies. Laboratory tests are ordered to evaluate blood counts, liver and kidney function, and nutritional markers. Some important tests include :-

   • Complete Blood Count (CBC) :- To detect anemia, which can result from internal bleeding or cancer

   • Liver Function Tests (LFTs) :- To evaluate possible metastasis or liver involvement

   • Tumor Markers :- In some cases, markers such as CEA (Carcinoembryonic Antigen) may be evaluated

   While lab tests alone cannot confirm the need for gastrectomy, they provide important clues about the severity of the condition.

3. Endoscopy :- Upper gastrointestinal (GI) endoscopy is one of the most critical diagnostic tools for evaluating gastric conditions. During this procedure, a flexible tube with a camera (endoscope) is inserted through the mouth and into the stomach to allow direct visualization of the stomach lining.

   Endoscopy helps the doctor :-

   • Identify tumors, ulcers, and areas of inflammation

   • Take biopsies from suspicious tissues for histopathological analysis

   • Determine the extent and location of disease

   If cancer is suspected or confirmed, additional tests are ordered to assess its stage and spread.

4. Biopsy and Histopathological Examination :- If a lesion or tumor is identified during endoscopy, the next step is a biopsy. A small sample of stomach tissue is removed and examined under a microscope by a pathologist. This examination helps :-

   • Confirm the presence of cancer

   • Determine the type and grade of cancer (e.g., adenocarcinoma, lymphoma)

   • Evaluate the aggressiveness of the tumor

   Biopsy results play a central role in deciding whether total gastrectomy is necessary or if less invasive treatment may be suitable.

Imaging Tests for Disease Staging

To decide if total gastrectomy is needed, doctors must understand how far the disease has progressed. Imaging studies help in staging the cancer and checking for metastasis. Common imaging tests include :-

1. CT Scan (Computed Tomography) :- A CT scan of the chest and abdomen helps detect the size and spread of a tumor to nearby organs like the liver, pancreas, or lymph nodes. It’s essential in surgical planning.
2. PET Scan (Positron Emission Tomography) :- PET scans are used to detect cancer spread (metastasis) that may not be visible on CT scans. They are particularly useful in advanced cancer evaluation.
3. Endoscopic Ultrasound (EUS) :- EUS combines endoscopy with ultrasound to get detailed images of the stomach wall and nearby lymph nodes. It is especially helpful in early cancer staging and assessing tumor invasion depth.
4. MRI (Magnetic Resonance Imaging) :- In certain cases, MRI may be used to assess soft tissue involvement or liver metastases.

Genetic Testing and Risk Evaluation

Some patients may undergo genetic testing if they have a family history of stomach cancer or specific inherited syndromes like hereditary diffuse gastric cancer (HDGC). A positive test for CDH1 gene mutations may warrant prophylactic (preventive) total gastrectomy, even if no symptoms or visible tumors are present.

Multidisciplinary Team Assessment

The decision for total gastrectomy is never made by one specialist alone. A multidisciplinary team (MDT) approach ensures comprehensive patient evaluation. This team often includes :-

1. Gastroenterologists

2. Surgical oncologists

3. Medical oncologists

4. Radiologists

5. Pathologists

6. Nutritionists

The team collaborates to interpret all diagnostic findings and determine the most appropriate treatment plan, including whether total gastrectomy is the best course of action.

Psychological and Nutritional Evaluation

Before proceeding with surgery, patients undergo nutritional and psychological assessments. Since total gastrectomy drastically affects how the body absorbs nutrients, patients may need dietary counseling and supplementation post-surgery. A pre-surgery nutrition plan is often recommended to improve strength and post-operative recovery.

Additionally, psychological support is offered to help patients mentally prepare for life after gastrectomy. Counseling helps patients adjust to the changes in eating habits, body image, and lifestyle.

Conclusion

Diagnosing the need for a total gastrectomy is a complex and multi step process that involves clinical evaluation, endoscopy, biopsy, imaging, and multidisciplinary consultation. Every diagnostic step is critical to ensuring that surgery is both necessary and likely to be beneficial. Understanding this process can empower patients to make informed decisions and better prepare for the road ahead.