Types of Total Gastrectomy

Total gastrectomy is most commonly performed for gastric adenocarcinoma, one of the most prevalent forms of stomach cancer, especially when tumors are located in the upper or middle part of the stomach. It is also indicated in individuals with genetic mutations such as CDH1, which significantly increase the risk of hereditary diffuse gastric cancer (HDGC). In such cases, the surgery may even be performed prophylactically before cancer develops to prevent the disease altogether.

When dealing with severe gastric conditions such as stomach cancer, severe ulcers, or inherited disorders like familial adenomatous polyposis (FAP), total gastrectomy often becomes a life saving surgical intervention. A total gastrectomy involves the complete removal of the stomach and reconstruction of the digestive tract to allow for food passage. Though this may sound drastic, modern surgical approaches have made this procedure safer and more effective than ever.

What is Total Gastrectomy?

Total gastrectomy is a surgical procedure where the entire stomach is removed. Since the stomach is a crucial organ for storing and digesting food, this surgery requires careful reconstruction of the digestive system typically by connecting the esophagus directly to the small intestine (usually the jejunum).

This procedure is usually indicated for :-

1. Advanced stomach cancer

2. Severe bleeding or perforated gastric ulcers

3. Hereditary cancer syndromes like hereditary diffuse gastric cancer (HDGC)

4. Refractory benign gastric diseases

Post-surgery, patients must adjust their eating habits significantly. However, with appropriate medical guidance and lifestyle changes, many lead healthy, fulfilling lives.

Types of Total Gastrectomy

There are several types of total gastrectomy based on the surgical approach and the reconstruction method used. Each type is chosen depending on the patient’s diagnosis, tumor location, and overall health.

1. Open Total Gastrectomy :- Open total gastrectomy is the traditional surgical technique where a large incision is made in the abdomen to access and remove the stomach. This approach is typically used when tumors are large, when the patient has had prior abdominal surgeries, or when a more extensive lymph node dissection is needed.

   Procedure Overview :-

   • A large incision provides direct visibility.

   • The entire stomach is removed.

   • The esophagus is connected to the jejunum using a Roux-en-Y reconstruction.

   • Nearby lymph nodes may be removed (lymphadenectomy) to ensure complete cancer clearance.

   Advantages :-

   • Direct access allows precise removal in complex cases.

   • Suitable for patients with advanced or complicated cancer.

   Considerations :-

   • Longer recovery time compared to minimally invasive techniques.

   • Increased postoperative pain and scarring.

2. Laparoscopic Total Gastrectomy :- Laparoscopic total gastrectomy is a minimally invasive surgery where small incisions are made, and the surgeon operates using a camera and specialized instruments.

   Procedure Overview :-

   • 4–6 small incisions are made in the abdomen.

   • A laparoscope (a thin tube with a camera) guides the procedure.

   • The stomach is removed through one of the incisions or via a small extended incision.

   • Reconstruction is usually done using the Roux-en-Y method.

   Advantages :-

   • Reduced blood loss and postoperative pain.

   • Faster recovery and shorter hospital stay.

   • Smaller scars and better cosmetic outcomes.

   Considerations :-

   • Requires high surgical expertise.

   • May not be suitable for very large tumors or complex cases.

3. Robotic Assisted Total Gastrectomy :- Robotic assisted total gastrectomy is an advanced version of the laparoscopic method, using a robotic surgical system for greater precision and flexibility.

   Procedure Overview :-

   • Similar port placements to laparoscopy.

   • Surgeon controls robotic arms from a console.

   • Enhanced dexterity allows for delicate tissue handling and reconstruction.

   Advantages :-

   • Increased precision and control.

   • Better visualization through 3D imaging.

   • Reduced complications in experienced hands.

   Considerations :-

   • Availability limited to advanced centers.

   • Higher costs than other methods.

4. Prophylactic Total Gastrectomy :- This type is performed not for current disease, but as a preventive measure in patients at high genetic risk for gastric cancer, such as those with CDH1 gene mutations (linked to hereditary diffuse gastric cancer).

   Procedure Overview :-

   • Can be done laparoscopically or through open surgery.

   • Entire stomach is removed despite no visible tumor.

   • Reconstruction is performed as with other techniques.

   Advantages :-

   • Significantly reduces the risk of future gastric cancer.

   • Often recommended in early adulthood before symptoms begin.

   Considerations :-

   • Major lifestyle changes despite no active disease.

   • Important to undergo genetic counseling and psychological support.

5. Extended Total Gastrectomy :- In some advanced cancer cases, an extended total gastrectomy may be needed. This procedure removes not only the stomach but also nearby organs or tissues affected by the tumor, such as the spleen, pancreas tail, or part of the esophagus.

   Procedure Overview :-

   • A highly complex, open procedure.

   • Involves en bloc removal of the stomach and other involved organs.

   • Extensive lymphadenectomy is also performed.

   Advantages :-

   • Offers a better chance of removing all cancerous tissue.

   • Improves survival rates in select patients.

   Considerations :-

   • Higher risk of complications.

   • Longer hospital stay and recovery time.

Recovery After Total Gastrectomy

Recovering from a total gastrectomy requires both physical healing and dietary adjustments. Initially, patients are placed on a liquid diet, gradually progressing to soft and then regular foods in small, frequent meals.

Some common post surgery challenges include :-

1. Dumping syndrome (rapid gastric emptying causing dizziness, nausea, or diarrhea)

2. Nutrient deficiencies (especially vitamin B12, iron, and calcium)

3. Weight loss

4. Changes in appetite

To support recovery :-

1. Nutritional supplements are often prescribed.

2. Regular follow-ups with a gastroenterologist and dietitian are essential.

3. Patients may require lifelong vitamin B12 injections due to the loss of intrinsic factor.

With proper guidance, many patients regain strength and adapt well to their new lifestyle.

Conclusion

Total gastrectomy is a significant yet often necessary procedure for individuals facing life threatening gastric conditions. The choice of surgical technique whether open, laparoscopic, robotic assisted, prophylactic, or extended depends on several factors including the stage and location of the disease, the patient’s health, and the expertise available.