Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Total gastrectomy and gastrointestinal reconstruction

Debrah Wirtzfeld, MD, MSc, FRCSC, FACS
Pamela Hebbard, MD, FRCS
Section Editor
David I Soybel, MD
Deputy Editor
Wenliang Chen, MD, PhD


The term “total gastrectomy” implies the complete removal of all gastric tissue. Total gastrectomy is the treatment of choice for certain gastric tumors.

Perioperative considerations, surgical techniques for total gastrectomy and gastrointestinal reconstruction, and complications of total gastrectomy are reviewed here. Issues pertaining to partial gastrectomy are discussed elsewhere. (See "Partial gastrectomy and gastrointestinal reconstruction".)

The gastroesophageal junction refers to the point of transition from the abdominal esophagus to the proximal stomach. Carcinomas arising at or near the gastroesophageal junction pose unique challenges, both in their ability to arise from esophageal or gastric mucosa, and in the complexity of jointly resecting the esophagus and stomach. Gastroesophageal junction tumors are reviewed elsewhere. (See "Multimodality approaches to potentially resectable esophagogastric junction and gastric cardia adenocarcinomas".)  


The surgical anatomy of the stomach, including the anatomic divisions of the stomach (cardia, fundus, body, antrum, and pyloric sphincter (figure 1)), blood supply, and lymphatic drainage, is reviewed elsewhere (figure 2). (See "Partial gastrectomy and gastrointestinal reconstruction", section on 'Surgical anatomy and physiology of the stomach'.)


Total gastrectomy is indicated in the treatment of certain gastric tumors. These include:


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Sep 2016. | This topic last updated: Nov 19, 2015.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
  1. Lynch HT, Kaurah P, Wirtzfeld D, et al. Hereditary diffuse gastric cancer: diagnosis, genetic counseling, and prophylactic total gastrectomy. Cancer 2008; 112:2655.
  2. Lynch HT, Silva E, Wirtzfeld D, et al. Hereditary diffuse gastric cancer: prophylactic surgical oncology implications. Surg Clin North Am 2008; 88:759.
  3. Brooks-Wilson AR, Kaurah P, Suriano G, et al. Germline E-cadherin mutations in hereditary diffuse gastric cancer: assessment of 42 new families and review of genetic screening criteria. J Med Genet 2004; 41:508.
  4. Dixon M, Cardoso R, Tinmouth J, et al. What studies are appropriate and necessary for staging gastric adenocarcinoma? Results of an international RAND/UCLA expert panel. Gastric Cancer 2014; 17:377.
  5. Birkmeyer JD, Sun Y, Wong SL, Stukel TA. Hospital volume and late survival after cancer surgery. Ann Surg 2007; 245:777.
  6. Fry DE. Surgical site infections and the surgical care improvement project (SCIP): evolution of national quality measures. Surg Infect (Larchmt) 2008; 9:579.
  7. Bratzler DW, Houck PM, Surgical Infection Prevention Guidelines Writers Workgroup, et al. Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. Clin Infect Dis 2004; 38:1706.
  8. Imamura H, Kurokawa Y, Tsujinaka T, et al. Intraoperative versus extended antimicrobial prophylaxis after gastric cancer surgery: a phase 3, open-label, randomised controlled, non-inferiority trial. Lancet Infect Dis 2012; 12:381.
  9. Mohri Y, Tonouchi H, Kobayashi M, et al. Randomized clinical trial of single- versus multiple-dose antimicrobial prophylaxis in gastric cancer surgery. Br J Surg 2007; 94:683.
  10. Schardey HM, Joosten U, Finke U, et al. The prevention of anastomotic leakage after total gastrectomy with local decontamination. A prospective, randomized, double-blind, placebo-controlled multicenter trial. Ann Surg 1997; 225:172.
  11. Farran L, Llop J, Sans M, et al. Efficacy of enteral decontamination in the prevention of anastomotic dehiscence and pulmonary infection in esophagogastric surgery. Dis Esophagus 2008; 21:159.
  12. Kehlet H. Fast-track colorectal surgery. Lancet 2008; 371:791.
  13. Lee MS, Lee JH, Park DJ, et al. Comparison of short- and long-term outcomes of laparoscopic-assisted total gastrectomy and open total gastrectomy in gastric cancer patients. Surg Endosc 2013; 27:2598.
  14. Kim HS, Kim BS, Lee IS, et al. Comparison of totally laparoscopic total gastrectomy and open total gastrectomy for gastric cancer. J Laparoendosc Adv Surg Tech A 2013; 23:323.
  15. Shinohara T, Satoh S, Kanaya S, et al. Laparoscopic versus open D2 gastrectomy for advanced gastric cancer: a retrospective cohort study. Surg Endosc 2013; 27:286.
  16. Lee JH, Nam BH, Ryu KW, et al. Comparison of outcomes after laparoscopy-assisted and open total gastrectomy for early gastric cancer. Br J Surg 2015; 102:1500.
  17. NCCN Gastric Cancer Guideline. Version 2.2013 http://www.nccn.org/professionals/physician_gls/f_guidelines.asp (Accessed on July 25, 2013).
  18. Dent DM, Madden MV, Price SK. Randomized comparison of R1 and R2 gastrectomy for gastric carcinoma. Br J Surg 1988; 75:110.
  19. Cuschieri A, Fayers P, Fielding J, et al. Postoperative morbidity and mortality after D1 and D2 resections for gastric cancer: preliminary results of the MRC randomised controlled surgical trial. The Surgical Cooperative Group. Lancet 1996; 347:995.
  20. Bonenkamp JJ, Hermans J, Sasako M, et al. Extended lymph-node dissection for gastric cancer. N Engl J Med 1999; 340:908.
  21. Sano T, Sasako M, Yamamoto S, et al. Gastric cancer surgery: morbidity and mortality results from a prospective randomized controlled trial comparing D2 and extended para-aortic lymphadenectomy--Japan Clinical Oncology Group study 9501. J Clin Oncol 2004; 22:2767.
  22. Kulig J, Popiela T, Kolodziejczyk P, et al. Standard D2 versus extended D2 (D2+) lymphadenectomy for gastric cancer: an interim safety analysis of a multicenter, randomized, clinical trial. Am J Surg 2007; 193:10.
  23. Yonemura Y, Wu CC, Fukushima N, et al. Randomized clinical trial of D2 and extended paraaortic lymphadenectomy in patients with gastric cancer. Int J Clin Oncol 2008; 13:132.
  24. Cuschieri A, Weeden S, Fielding J, et al. Patient survival after D1 and D2 resections for gastric cancer: long-term results of the MRC randomized surgical trial. Surgical Co-operative Group. Br J Cancer 1999; 79:1522.
  25. Nunobe S, Hiki N, Fukunaga T, et al. Laparoscopy-assisted pylorus-preserving gastrectomy: preservation of vagus nerve and infrapyloric blood flow induces less stasis. World J Surg 2007; 31:2335.
  26. Ando S, Tsuji H. Surgical technique of vagus nerve-preserving gastrectomy with D2 lymphadenectomy for gastric cancer. ANZ J Surg 2008; 78:172.
  27. Lehnert T, Buhl K. Techniques of reconstruction after total gastrectomy for cancer. Br J Surg 2004; 91:528.
  28. Sharma D. Choice of digestive tract reconstructive procedure following total gastrectomy: A critical reappraisal. Indian J Surg 2004; 66:270.
  29. Gertler R, Rosenberg R, Feith M, et al. Pouch vs. no pouch following total gastrectomy: meta-analysis and systematic review. Am J Gastroenterol 2009; 104:2838.
  30. Menon P, Sunil I, Chowdhury SK, Rao KL. Hunt-Lawrence pouch after total gastrectomy: 4 years follow up. Indian Pediatr 2003; 40:249.
  31. HUNT CJ. Construction of food pouch from segment of jejunum as substitute for stomach in total gastrectomy. AMA Arch Surg 1952; 64:601.
  32. LAWRENCE W Jr. Reservoir construction after total gastrectomy: an instructive case. Ann Surg 1962; 155:191.
  33. Lawrence W Jr. Reconstruction after total gastrectomy: what is preferred technique? J Surg Oncol 1996; 63:215.
  34. El Halabi HM, Lawrence W Jr. Clinical results of various reconstructions employed after total gastrectomy. J Surg Oncol 2008; 97:186.
  35. Fein M, Fuchs KH, Thalheimer A, et al. Long-term benefits of Roux-en-Y pouch reconstruction after total gastrectomy: a randomized trial. Ann Surg 2008; 247:759.
  36. Hocking MP, Vogel SB, Falasca CA, Woodward ER. Delayed gastric emptying of liquids and solids following Roux-en-Y biliary diversion. Ann Surg 1981; 194:494.
  37. Harrison WD, Hocking MP, Vogel SB. Gastric emptying and myoelectric activity following Roux-en-Y gastrojejunostomy. J Surg Res 1990; 49:385.
  38. Eagon JC, Miedema BW, Kelly KA. Postgastrectomy syndromes. Surg Clin North Am 1992; 72:445.
  39. Schwarz A, Büchler M, Usinger K, et al. Importance of the duodenal passage and pouch volume after total gastrectomy and reconstruction with the Ulm pouch: prospective randomized clinical study. World J Surg 1996; 20:60.
  40. Tsujimoto H, Sakamoto N, Ichikura T, et al. Optimal size of jejunal pouch as a reservoir after total gastrectomy: a single-center prospective randomized study. J Gastrointest Surg 2011; 15:1777.
  41. Doglietto GB, Papa V, Tortorelli AP, et al. Nasojejunal tube placement after total gastrectomy: a multicenter prospective randomized trial. Arch Surg 2004; 139:1309.
  42. Shellito PC, Malt RA. Tube gastrostomy. Techniques and complications. Ann Surg 1985; 201:180.
  43. Sun Z, Shenoi MM, Nussbaum DP, et al. Feeding jejunostomy tube placement during resection of gastric cancers. J Surg Res 2016; 200:189.
  44. Dann GC, Squires MH 3rd, Postlewait LM, et al. An assessment of feeding jejunostomy tube placement at the time of resection for gastric adenocarcinoma: A seven-institution analysis of 837 patients from the U.S. gastric cancer collaborative. J Surg Oncol 2015; 112:195.
  45. Patel SH, Kooby DA, Staley CA 3rd, Maithel SK. An assessment of feeding jejunostomy tube placement at the time of resection for gastric adenocarcinoma. J Surg Oncol 2013; 107:728.
  46. Hartgrink HH, van de Velde CJ, Putter H, et al. Extended lymph node dissection for gastric cancer: who may benefit? Final results of the randomized Dutch gastric cancer group trial. J Clin Oncol 2004; 22:2069.
  47. Newman EA, Mulholland MW. Prophylactic gastrectomy for hereditary diffuse gastric cancer syndrome. J Am Coll Surg 2006; 202:612.
  48. Lewis FR, Mellinger JD, Hayashi A, et al. Prophylactic total gastrectomy for familial gastric cancer. Surgery 2001; 130:612.
  49. Sierzega M, Kolodziejczyk P, Kulig J, Polish Gastric Cancer Study Group. Impact of anastomotic leakage on long-term survival after total gastrectomy for carcinoma of the stomach. Br J Surg 2010; 97:1035.
  50. Lang H, Piso P, Stukenborg C, et al. Management and results of proximal anastomotic leaks in a series of 1114 total gastrectomies for gastric carcinoma. Eur J Surg Oncol 2000; 26:168.
  51. Fukagawa T, Gotoda T, Oda I, et al. Stenosis of esophago-jejuno anastomosis after gastric surgery. World J Surg 2010; 34:1859.
  52. Liedman B, Andersson H, Bosaeus I, et al. Changes in body composition after gastrectomy: results of a controlled, prospective clinical trial. World J Surg 1997; 21:416.
  53. Svedlund J, Sullivan M, Liedman B, et al. Quality of life after gastrectomy for gastric carcinoma: controlled study of reconstructive procedures. World J Surg 1997; 21:422.