A gastrectomy is a partial or total surgical removal of the

stomach The stomach is a muscular, hollow organ in the gastrointestinal tract of humans and many other animals, including several invertebrates. The stomach has a dilated structure and functions as a vital organ in the digestive system. The stomach i ...

Indications

Gastrectomies are performed to treat

stomach cancer Stomach cancer, also known as gastric cancer, is a cancer that develops from the lining of the stomach. Most cases of stomach cancers are gastric carcinomas, which can be divided into a number of subtypes, including gastric adenocarcinomas. Lymph ...

and

perforations A perforation is a small hole in a thin material or web. There is usually more than one perforation in an organized fashion, where all of the holes collectively are called a ''perforation''. The process of creating perforations is called perfor ...

of the stomach wall. In severe duodenal ulcers it may be necessary to remove the lower portion of the stomach called the

pylorus The pylorus ( or ), or pyloric part, connects the stomach to the duodenum. The pylorus is considered as having two parts, the ''pyloric antrum'' (opening to the body of the stomach) and the ''pyloric canal'' (opening to the duodenum). The ''pylori ...

and the upper portion of the

small intestine The small intestine or small bowel is an organ in the gastrointestinal tract where most of the absorption of nutrients from food takes place. It lies between the stomach and large intestine, and receives bile and pancreatic juice through the p ...

called the

duodenum The duodenum is the first section of the small intestine in most higher vertebrates, including mammals, reptiles, and birds. In fish, the divisions of the small intestine are not as clear, and the terms anterior intestine or proximal intestine m ...

. If there is a sufficient portion of the upper duodenum remaining a Billroth I procedure is performed, where the remaining portion of the stomach is reattached to the duodenum before the

bile duct A bile duct is any of a number of long tube-like structures that carry bile, and is present in most vertebrates. Bile is required for the digestion of food and is secreted by the liver into passages that carry bile toward the hepatic duct. It ...

and the duct of the

pancreas The pancreas is an organ of the digestive system and endocrine system of vertebrates. In humans, it is located in the abdomen behind the stomach and functions as a gland. The pancreas is a mixed or heterocrine gland, i.e. it has both an end ...

. If the stomach cannot be reattached to the duodenum a

Billroth II Billroth II, more formally Billroth's operation II, is an operation in which a partial gastrectomy (removal of the stomach) is performed and the cut end of the stomach is closed. The greater curvature of the stomach (not involved with the previo ...

is performed, where the remaining portion of the duodenum is sealed off, a hole is cut into the next section of the small intestine called the

jejunum The jejunum is the second part of the small intestine in humans and most higher vertebrates, including mammals, reptiles, and birds. Its lining is specialised for the absorption by enterocytes of small nutrient molecules which have been previou ...

and the stomach is reattached at this hole. As the pylorus is used to grind food and slowly release the food into the small intestine, removal of the pylorus can cause food to move into the small intestine faster than normal, leading to

gastric dumping syndrome Dumping syndrome occurs when food, especially sugar, moves too quickly from the stomach to the duodenum—the first part of the small intestine—in the upper gastrointestinal (GI) tract. This condition is also called rapid gastric emptying. It i ...

Polya's operation

Also known as the Reichel–Polya operation, this is a type of posterior gastroenterostomy which is a modification of the Billroth II operation developed by

Eugen Pólya Jenő Sándor Pólya, german: Eugen Alexander Pólya, hu, Pólya (Pollák) Jenő Sándor (April 30, 1876 – 1944) was a Hungarian surgeon who was a native of Budapest. He was the brother of George Pólya (1887–1985), who was a professor of m ...

and

Friedrich Paul Reichel Friedrich Paul Reichel (born 23 December 1858 in Breslau, died December 1934) was a German surgeon. 1881 - 1885: Assistant (Breslau - Surgery - Fischer) 1882: Doctor of medicine 1885 - 1888: Assistant (Berlin - Gynecology - Karl Ludwig Ernst ...

. It involves a resection of 2/3 of the

with blind closure of the duodenal stump and a retrocolic gastro- jejunal

anastomosis An anastomosis (, plural anastomoses) is a connection or opening between two things (especially cavities or passages) that are normally diverging or branching, such as between blood vessels, leaf#Veins, leaf veins, or streams. Such a connection m ...

Post-operative effects

The most obvious effect of the removal of the stomach is the loss of a storage place for food while it is being digested. Since only a small amount of food can be allowed into the small intestine at a time, the patient will have to eat small amounts of food regularly in order to prevent

. Another major effect is the loss of the intrinsic-factor-secreting

parietal cell Parietal cells (also known as oxyntic cells) are epithelial cells in the stomach that secrete hydrochloric acid (HCl) and intrinsic factor. These cells are located in the gastric glands found in the lining of the fundus and body regions of the s ...

s in the stomach lining. Intrinsic factor is essential for the uptake of vitamin B₁₂ in the

terminal ileum The ileum () is the final section of the small intestine in most higher vertebrates, including mammals, reptiles, and birds. In fish, the divisions of the small intestine are not as clear and the terms posterior intestine or distal intestine ma ...

and without it the patient will develop a vitamin B₁₂ deficiency. This can lead to a type of

anaemia Anemia or anaemia (British English) is a blood disorder in which the blood has a reduced ability to carry oxygen due to a lower than normal number of red blood cells, or a reduction in the amount of hemoglobin. When anemia comes on slowly, th ...

known as

megaloblastic anaemia Megaloblastic anemia is a type of macrocytic anemia. An anemia is a red blood cell defect that can lead to an undersupply of oxygen. Megaloblastic anemia results from inhibition of DNA synthesis during red blood cell production. When DNA synth ...

(can also be caused by

folate deficiency Folate deficiency, also known as vitamin B9 deficiency, is a low level of folate and derivatives in the body. Signs of folate deficiency are often subtle. A low number of red blood cells (anemia) is a late finding in folate deficiency and folate ...

, or

autoimmune disease An autoimmune disease is a condition arising from an abnormal immune response to a functioning body part. At least 80 types of autoimmune diseases have been identified, with some evidence suggesting that there may be more than 100 types. Nearly a ...

where it is specifically known as

pernicious anaemia Pernicious anemia is a type of vitamin B12 deficiency anemia, a disease in which not enough red blood cells are produced due to the malabsorption of vitamin B12. Malabsorption in pernicious anemia results from the lack or loss of intrinsic ...

) which severely reduces red-blood cell synthesis (known as

erythropoiesis Erythropoiesis (from Greek 'erythro' meaning "red" and 'poiesis' "to make") is the process which produces red blood cells (erythrocytes), which is the development from erythropoietic stem cell to mature red blood cell. It is stimulated by decrea ...

, as well as other haematological

cell lineage Cell lineage denotes the developmental history of a tissue or organ from the fertilized embryo. This is based on the tracking of an organism's cellular ancestry due to the cell divisions and relocation as time progresses, this starts with the orig ...

s if severe enough but the red cell is the first to be affected). This can be treated by giving the patient direct injections of vitamin B₁₂.

Iron-deficiency anemia Iron-deficiency anemia is anemia caused by a iron deficiency, lack of iron. Anemia is defined as a decrease in the number of red blood cells or the amount of hemoglobin in the blood. When onset is slow, symptoms are often vague such as Fatigue (me ...

can occur as the stomach normally converts iron into its absorbable form. Another side effect is the loss of

ghrelin Ghrelin (; or lenomorelin, INN) is a hormone produced by enteroendocrine cells of the gastrointestinal tract, especially the stomach, and is often called a "hunger hormone" because it increases the drive to eat. Blood levels of ghrelin are highe ...

production, which has been shown to be compensated after a while. Lastly, this procedure is post-operatively associated with decreased bone density and higher incidence of bone fractures. This may be due to the importance of gastric acid in

calcium Calcium is a chemical element with the symbol Ca and atomic number 20. As an alkaline earth metal, calcium is a reactive metal that forms a dark oxide-nitride layer when exposed to air. Its physical and chemical properties are most similar to ...

absorption. Post-operatively, up to 70% of patients undergoing total gastrectomy develop complications such as dumping syndrome and reflux esophagitis. A meta-analysis of 25 studies found that construction of a "pouch", which serves as a "stomach substitute", reduced the incidence of dumping syndrome and reflux esophagitis by 73% and 63% respectively, and led to improvements in quality-of-life, nutritional outcomes, and body mass index. After Bilroth II surgery, a small amount of residual gastric tissue may remain in the duodenum. The alkaline environment causes the retained gastric tissue to produce acid, which may result in ulcers in a rare complication known as

retained antrum syndrome Retained antrum syndrome or retained gastric antrum syndrome is one of the rare postgastrectomy syndromes. It happens after Billroth II surgery and the mechanism involved is the inadequate removal of the distal antrum and pylorus during resection ...

. All patients lose weight after gastrectomy, although the extent of weight loss is dependent on the extent of surgery (total gastrectomy vs partial gastrectomy) and the pre-operative BMI. Maximum weight loss occurs by 12 months and many patients regain weight afterwards.

History

The first successful gastrectomy was performed by

Theodor Billroth Christian Albert Theodor Billroth (26 April 18296 February 1894) was a German surgeon and amateur musician. As a surgeon, he is generally regarded as the founding father of modern abdominal surgery. As a musician, he was a close friend and conf ...

in 1881 for cancer of the stomach. Historically, gastrectomies were used to treat

peptic ulcer Peptic ulcer disease (PUD) is a break in the inner lining of the stomach, the first part of the small intestine, or sometimes the lower esophagus. An ulcer in the stomach is called a gastric ulcer, while one in the first part of the intestines i ...

s.E. Pólya:Zur Stumpfversorgung nach Magenresektion. Zentralblatt für Chirurgie, Leipzig, 1911, 38: 892-894. These are now usually treated with

antibiotic An antibiotic is a type of antimicrobial substance active against bacteria. It is the most important type of antibacterial agent for fighting bacterial infections, and antibiotic medications are widely used in the treatment and prevention of ...

s, as it was recognized that they are usually due to ''

Helicobacter pylori ''Helicobacter pylori'', previously known as ''Campylobacter pylori'', is a gram-negative, microaerophilic, spiral (helical) bacterium usually found in the stomach. Its helical shape (from which the genus name, helicobacter, derives) is though ...

'' infection or chemical imbalances in the gastric juices. In the past a gastrectomy for peptic ulcer disease was often accompanied by a

vagotomy A vagotomy is a surgery, surgical procedure that involves segmental resection, removing part of the vagus nerve. Types A plain vagotomy eliminates the parasympathetic supply from the stomach to the left side of the transverse colon. Other techni ...

, to reduce acid production. This problem is now managed with

proton pump inhibitor Proton-pump inhibitors (PPIs) are a class of medications that cause a profound and prolonged reduction of stomach acid production. They do so by irreversibly inhibiting the stomach's H+/K+ ATPase proton pump. They are the most potent inhibitors ...

References

{{Digestive system surgical procedures Digestive system surgery

Indications

Polya's operation

Post-operative effects

History

See also

References