Total gastrectomy and gastrointestinal reconstruction

INTRODUCTION — 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 surgical management of invasive gastric cancer is discussed in another topic. (See "Surgical management of invasive gastric cancer".)

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 management of hereditary diffuse gastric cancer (cadherin-1 [CDH1] mutation), both in the prophylactic setting and when invasive gastric cancer has been confirmed, is discussed in another topic. (See "Surgical management of hereditary diffuse gastric cancer".)

Laparoscopic gastrectomy for cancer is discussed in detail elsewhere. (See "Laparoscopic gastrectomy for cancer".)

SURGICAL ANATOMY AND PHYSIOLOGY OF THE STOMACH — 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'.)

INDICATIONS — Total gastrectomy is indicated in the treatment of certain gastric tumors. These include (see "Surgical management of invasive gastric cancer", section on 'Total versus partial gastrectomy'):

●Gastric adenocarcinoma affecting the proximal stomach. (See "Surgical management of invasive gastric cancer", section on 'Proximal and esophagogastric junction tumors'.)

●Gastrointestinal stromal tumors affecting the proximal stomach, where a more limited resection is not technically feasible. (See "Local treatment for gastrointestinal stromal tumors, leiomyomas, and leiomyosarcomas of the gastrointestinal tract".)

●Type 3 or 4 gastric carcinoid affecting the proximal stomach. (See "Staging, treatment, and post-treatment surveillance of non-metastatic, well-differentiated gastrointestinal tract neuroendocrine (carcinoid) tumors", section on 'Stomach'.)

●Hereditary diffuse gastric cancer (CDH1 mutation), both in the prophylactic setting and when invasive gastric cancer has been confirmed. (See "Surgical management of hereditary diffuse gastric cancer".)

●Signet ring carcinoma, a diffuse form of gastric carcinoma, may benefit from total gastrectomy due to this tumor's diffuse submucosal spread and difficulty in obtaining clear margins with subtotal gastrectomy. (See "Clinical features, diagnosis, and staging of gastric cancer".)

●Benign indications for total gastrectomy are rare but include hemorrhagic gastritis that has failed medical and endoscopic management and intractable symptoms related to altered gastric physiology in patients who have undergone partial gastrectomy and reconstruction. (See "Management of stress ulcers", section on 'Subtotal or total gastrectomy' and "Postgastrectomy complications".)

Contraindications — Total gastrectomy should not be performed under the following circumstances:

●Patients with metastatic disease who are asymptomatic or minimally symptomatic should not undergo total gastrectomy, unless performed in the context of a clinical trial. The only published randomized controlled trial of chemotherapy versus surgery plus chemotherapy failed to show any benefit in adding surgery to the treatment plan [1]. Furthermore, the primary treatment of metastatic gastric cancer is chemotherapy, and total gastrectomy (which is associated with significant morbidities) can delay or prevent the patient from receiving treatment. Symptoms of obstruction are best managed by stenting, bypass, distal feeding tube, or palliative care. (See "Initial systemic therapy for locally advanced unresectable and metastatic esophageal and gastric cancer" and "Adjuvant and neoadjuvant treatment of gastric cancer".)

●Total gastrectomy should not be performed when a partial gastrectomy would provide negative margins, due to the increased risk of complications associated with total gastrectomy compared with partial resection. The exception would be known or suspected hereditary diffuse gastric cancer, which mandates removal of the entire stomach because of the risk of a future malignancy in any gastric remnant. (See "Surgical management of hereditary diffuse gastric cancer".)

●Patients with significant medical comorbidities, particularly those with major cardiovascular and respiratory disease, may not be acceptable candidates for total gastrectomy, which is associated with significant morbidity and mortality. (See 'Perioperative morbidity and mortality' below.)

●Since the patient can be expected to lose weight following total gastrectomy, total gastrectomy may not be appropriate for patients who are malnourished. Various clinical scoring systems based on biochemical factors such as albumin have been proposed to define malnutrition in the context of gastric cancer surgery [2]. Some patients with malignancy-related malnutrition, particularly after neoadjuvant therapy, may become better candidates for resection following a period of nutritional supplementation [3]. (See "Overview of perioperative nutrition support", section on 'Preoperative nutrition support'.)

TUMOR STAGING — Prior to total gastrectomy, the patient should undergo preoperative staging to assess the extent of disease, including abdominal imaging, upper endoscopy, and staging laparoscopy (only for adenocarcinoma).

Imaging — Preoperative chest and abdominal computed tomography (CT) should be performed to rule out metastatic disease, which contraindicates gastrectomy [4]. Positron emission tomography (PET) scanning is not routinely performed but may be used to evaluate equivocal findings on other imaging studies. Inconclusive results may need further focused imaging or staging laparoscopy to definitively confirm or rule out metastases. (See 'Staging laparoscopy' below.)

Endoscopy — Preoperative endoscopic evaluation should be used to assess the location of the tumor and its proximity to the gastroesophageal junction. The position of the gastroesophageal junction and the presence of hiatal hernia should also be noted. Total gastrectomy in patients with a shortened esophagus may require extension of the incision into the thorax.

Staging laparoscopy — In patients undergoing total gastrectomy for gastric adenocarcinoma, staging laparoscopy can be used to rule out metastatic disease, particularly carcinomatosis, and avoid unnecessary laparotomy. In one systematic review, staging laparoscopy changed management in 60 percent of patients with gastric cancer [5].

Whether all patients with adenocarcinoma require staging laparoscopy prior to total gastrectomy or just those with advanced disease is controversial. Most experts recommend staging laparoscopy for patients who have locally advanced disease (T3 or T4), have nodal metastasis (N+), or may require multivisceral resection [6,7].

The laparoscopy may be performed as a standalone procedure or just prior to the planned gastrectomy. As neoadjuvant chemotherapy becomes more commonly used in gastric cancer, staging laparoscopy is increasingly performed as a standalone procedure prior to the initiation of chemotherapy. This timing allows all involved to have information regarding the curability of the tumor prior to embarking on a treatment plan. (See "Surgical management of invasive gastric cancer", section on 'Staging laparoscopy'.)

The indications for staging laparoscopy and general procedural details for performing staging laparoscopy for digestive malignancies are discussed elsewhere. (See "Clinical features, diagnosis, and staging of gastric cancer", section on 'Staging laparoscopy' and "Diagnostic staging laparoscopy for digestive system cancers".)

PREOPERATIVE PREPARATION

Medical risk assessment — Assessment of operative risk prior to gastric resection should identify the presence of other medical comorbidities, which may preclude resection. In general, patients undergoing total gastrectomy are older. In the United States, gastric cancer is most frequently diagnosed among people aged 65 to 74 years; the average age at diagnosis is 69 [8]. Since most total gastric resections are performed under elective circumstances, there is adequate time for risk assessment and optimization of the patient's medical status. Preoperative medical assessment is discussed elsewhere. (See "Evaluation of cardiac risk prior to noncardiac surgery" and "Evaluation of perioperative pulmonary risk".)

Antibiotics — Antibiotic prophylaxis is recommended for procedures that enter into the lumen of the gastrointestinal tract. (See "Antimicrobial prophylaxis for prevention of surgical site infection following gastrointestinal procedures in adults", section on 'Gastroduodenal procedures'.)

Appropriate antibiotic choices are given in the table (table 1). Patients should receive intravenous antibiotics prior to the incision, and dosing should be repeated intraoperatively for cases lasting more than three hours [9,10]. Randomized trials in patients undergoing gastrectomy (partial or total) have found no benefit for longer-duration postoperative antibiotics over perioperative (24 hour) dosing [11,12].

Bowel preparation and decontamination — Although some surgeons routinely prepare the bowel prior to a total gastrectomy, such practice may not be necessary. Even if a part of the colon unexpectedly requires en bloc resection with a large gastric tumor, right colectomy can be done safely without mechanical bowel preparation.

However, there may be a role for oral enteral decontamination [13,14]. One trial that evaluated oral antibiotic decontamination prior to total gastrectomy randomly assigned 260 patients to placebo or oral decontamination with polymyxin B (100 mg), tobramycin (80 mg), vancomycin (125 mg), and amphotericin B (500 mg) four times per day orally from the day before the operation until postoperative day seven [13]. On intention-to-treat analysis, significantly fewer esophagojejunostomy anastomotic leaks occurred in the oral decontamination group compared with the placebo group (2.9 versus 10.6 percent). The rate of pulmonary infection was also significantly lower among those who received oral decontamination (8.8 versus 22.3 percent). Mortality rates were not significantly different. Unfortunately, there was a high dropout rate during follow-up (55 of 260 patients). A subsequent smaller trial did not find a significant difference [14].

Contemporary observational studies in gastrointestinal surgery reported low anastomotic leak rate with oral decontamination [15], but no newer trials have been reported. Additional well-designed trials will be needed before routine oral decontamination can be recommended for gastric cancer surgery.

Thromboprophylaxis — Patients undergoing total gastrectomy for malignancy are at moderate-to-high risk for thromboembolism due to the nature and duration of the procedure, and pharmacologic prophylaxis is recommended (table 2). We also place intermittent pneumatic compression devices on all patients prior to induction of anesthesia and continue their use until the patient is ambulatory. (See "Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients".)

GENERAL CONSIDERATIONS

Anesthesia — Total gastrectomy is performed under general anesthesia. For patients undergoing upper abdominal surgery, a transversus abdominis plane block or thoracic epidural anesthesia may simplify postoperative pain management and allow early postoperative mobilization, which may expedite the return of gastrointestinal function. (See "Abdominal nerve block techniques", section on 'Transversus abdominis plane (TAP) blocks' and "Epidural and combined spinal-epidural anesthesia: Techniques".)

Open versus minimally invasive total gastrectomy — A total gastrectomy can be performed via an open or minimally invasive (laparoscopic or robotic) approach. Each approach is technically demanding and best performed by surgeons with advanced skills and training. Although various groups have reported satisfactory short- and long-term outcomes from laparoscopic total gastrectomy [16,17], it should be noted that these reports are almost exclusively from high-volume cancer hospitals with extensive laparoscopic experience.

Laparoscopic gastric cancer surgery is discussed elsewhere. (See "Laparoscopic gastrectomy for cancer", section on 'Laparoscopic total gastrectomy'.)

Margins of resection — For cancer resection, frozen sections at the proximal and distal gastric margins should be obtained to be certain that the margins are free of carcinoma and ensure an R0 resection. The required proximal resection margin determines if a subtotal or total gastrectomy is required, especially for midgastric tumors. A proximal margin of at least 3 cm for tumors with an expansive growth pattern and at least 5 cm for tumors with an infiltrative growth pattern was proposed in Asian guidelines [18,19] and accepted by Western surgeons [20]. A positive margin (R1) is associated with worse five-year survival (hazard ratio 2.06, 95% CI 1.61-2.65) [21].

When performing prophylactic gastrectomy for hereditary diffuse gastric cancer, the distal resection should be carried at least 1 cm distal to the pylorus. Frozen sections should be obtained of the proximal margin to confirm that all gastric mucosa has been removed. If gastric mucosa at the proximal resection is identified, a more proximal resection to esophageal mucosa is needed. Extension of the incision into the left thorax may be needed to achieve an adequate proximal margin in patients with a shortened esophagus. (See "Surgical management of hereditary diffuse gastric cancer", section on 'Margins of resection'.)

In the setting of gastrointestinal stromal tumors (GISTs), frozen section evaluation may not be necessary, since the gross margin is representative of the microscopic extent of the tumor.

Extent of nodal dissection — The required extent of lymphadenectomy depends on the tumor. In the rare instance of total gastrectomy for benign reasons, lymph node dissection is not required.

Gastric adenocarcinoma — A formal lymph node dissection is required for invasive carcinomas, but the optimal extent of lymph node dissection remains controversial. The lymph node stations (table 3) are grouped according to location (figure 3) and follow the extent of lymph node dissection (D1 through D3). (See "Surgical management of invasive gastric cancer", section on 'Extent of lymph node dissection' and "Partial gastrectomy and gastrointestinal reconstruction", section on 'Lymph node dissection'.)

Currently, a D2 dissection is the standard approach in Eastern countries (eg, Japan) [18] and the recommended approach in experienced centers in the West [7]. Compared with D1 dissection, which is the minimal accepted standard for cancer surgery, D2 dissection is associated with fewer local recurrences (12 versus 22 percent), regional recurrences (13 versus 19 percent), and cancer-related deaths (37 versus 48 percent) at 15 years [22]. Although D2 dissection is associated with higher morbidity, mortality, and reoperation rate, such detriments were largely attributed to adjacent organ resection (ie, distal pancreatectomy and splenectomy), which is not included in the modern D2 dissection. Lymph node dissections that are more radical than D2 (eg, D2 plus paraaortic nodes, D3, or D4) should not be performed routinely, as randomized trials fail to show a survival benefit for more aggressive surgery [23-26]. Regardless of type of lymph node dissection, a minimum of 16 lymph nodes should be harvested to ensure accurate staging of the patient [27].

A detailed description of the definitions of the extent of lymph node dissections for gastric cancer is provided elsewhere. (See "Surgical management of invasive gastric cancer", section on 'Extent of lymph node dissection'.)

Gastrointestinal stromal tumors — No lymph node dissection is required for GISTs, as lymph node metastases are rare.

Type 3 or 4 gastric carcinoid — Due to the rarity of this tumor, there are no large studies available to examine outcomes related to the extent of lymph node dissection [28,29]. However, since lymph node metastases are common with gastric carcinoid, a lymph node dissection should be performed as with gastric carcinoma [30,31]. (See "Staging, treatment, and post-treatment surveillance of non-metastatic, well-differentiated gastrointestinal tract neuroendocrine (carcinoid) tumors", section on 'Stomach'.)

Prophylactic gastrectomy — During prophylactic total gastrectomy for those with CDH1 mutation, only those lymph nodes that are harvested with the gastrectomy specimen are removed. A formal lymph node dissection is not needed. (See "Surgical management of hereditary diffuse gastric cancer".)

Adjacent organ resection — Unless there is direct tumor extension or lymph node metastasis, splenectomy, pancreatectomy, or bursectomy should not be performed routinely with total gastrectomy [32]. As discussed in this section, there is good evidence that performing such adjacent organ resection increases the morbidity and mortality of total gastrectomy without improving survival.

Splenectomy — Splenectomy used to be performed in Japan as a part of total gastrectomy for proximal gastric cancer to facilitate complete lymphadenectomy at the splenic hilum. However, it can add to the morbidities (54 percent) and mortality (16 percent) of gastric cancer surgery and was thought to mask the benefit of D2 lymphadenectomy in early trials [33]. In the JCOG 0110 trial, which included 505 patients undergoing total gastrectomy for proximal gastric cancer, splenectomy was associated with a high morbidity (30.3 percent) but low mortality (0.4 percent) and did not improve five-year overall survival (75.1 percent splenectomy versus 76.4 percent no splenectomy) or five-year recurrence-free survival (68.4 versus 70.5 percent) [34].

Distal pancreatectomy — Similar to splenectomy, the purpose of performing a distal pancreatectomy with total gastrectomy is to ensure a complete D2 lymphadenectomy. However, pancreatectomy was associated with high morbidity and mortality rates in early trials and thus diminishing purported oncologic benefits [35,36]. In a trial of 110 patients under total gastrectomy with D2 dissection, patients who underwent pancreatectomy and splenectomy had higher morbidity (eg, diabetes) and mortality rates than those who underwent splenectomy alone but no five-year overall survival benefit [37].

Bursectomy — A bursectomy is a dissection of the peritoneal lining covering the pancreas and the anterior aspect of the transverse mesocolon. It was mainly performed to remove possible free cancer cells or micrometastasis, especially for posterior gastric cancer that invades the serosa [38]. A trial (JCOG 1001) that included 1204 patients with cT3-4 did not find a benefit for bursectomy in five-year overall survival, recurrence-free survival, or recurrence rate [39].

Vagus nerve preservation — During skeletonization of the distal esophagus, hepatic and celiac branches of the anterior and posterior vagal nerves, respectively, should be preserved. In a systematic review and meta-analysis of seven retrospective comparative studies and one trial, gastrectomy with preservation of the celiac and hepatic branches of the vagus nerve reduced the time to first flatus (weighted mean difference -0.436, 95% CI -0.603 to -0.269) and hospital stay (weighted mean difference -0.456, 95% CI -0.874 to -0.037) compared with not preserving those nerves. Nerve preservation was also associated with a lower incidence of gallstones (odds ratio 0.582, 95% CI 0.356-0.953) and a lower incidence of bile reflux (odds ratio 0.473, 95% CI 0.280-0.800) but not rates of diarrhea, early dumping syndrome, esophageal reflux, and delayed gastric emptying [40]. (See 'Total gastrectomy' below and "Postgastrectomy complications", section on 'Postvagotomy diarrhea'.)

PROCEDURE — Once the abdomen has been entered, total gastrectomy is performed by exposing and isolating the stomach, then dividing the esophagus and proximal duodenum and removing the specimen. Surgical margins are evaluated with frozen section, as indicated, and, if clear, reconstruction is undertaken to restore gastrointestinal continuity. (See 'Margins of resection' above and 'Gastrointestinal reconstruction' below.)

Incision — Because a thoracotomy may be needed to obtain a clear proximal margin, the patient should be prepared and draped for that possibility. An upper abdominal midline incision from the xiphoid process of the sternum to the umbilicus is generally adequate. Alternatively, a bilateral subcostal (ie, chevron) incision may be used with similar exposure. (See "Incisions for open abdominal surgery".)

Once the abdomen is entered, the left triangular ligament of the liver should be taken down. A self-retaining retractor (eg, Thompson, Omni) can be used to retract the upper abdominal wall and left lateral lobe of the liver to provide better exposure of hiatus and the gastroesophageal junction.

Total gastrectomy — To resect the stomach:

●Take the greater omentum off the transverse colon and mesocolon inferiorly to resect the omentum with the stomach en bloc when managing gastric carcinoma (figure 4). For prophylactic gastrectomy, the greater omentum can be preserved with the transverse mesocolon inferiorly (figure 5).

●Identify the pylorus (figure 6) and mark it with a suture (eg, 3-0 Prolene).

●Ligate the right gastric and right gastroepiploic vessels at their base (figure 6).

●Transect the duodenum distal to the pylorus using a gastrointestinal anastomosis (GIA) stapler (figure 7). Care is taken to avoid injury to biliary and portal structures. Some surgeons also imbricate the staple line of the duodenal stump to prevent a duodenal stump leak. (See "Postgastrectomy duodenal leak", section on 'Prevention'.)

●Continue the dissection cephalad along the lesser curvature of the stomach by dividing and ligating the gastrohepatic ligament toward the diaphragm (figure 8).

●Identify and divide the left gastric vessels (figure 8). Dissect along the greater curvature of the stomach just outside the gastroepiploic arcade.

●Encircle the esophagus with a Penrose drain and divide each crus of the diaphragm. Skeletonize the distal esophagus but preserve the hepatic and celiac branches of the anterior and posterior vagus without compromising an adequate nodal dissection if the surgeon is familiar with the technique. Place four stay sutures (eg, 2-0 Prolene) circumferentially in the esophagus approximately 2 cm proximal to the presumed gastroesophageal junction. (See 'Vagus nerve preservation' above.)

●Transect the distal esophagus using a pursestring device (figure 9). Place the anvil of the end-to-end anastomosis (EEA) stapler into the distal esophagus, which will be used to create the esophagojejunal anastomosis, and tighten the pursestring suture. (See 'Gastrointestinal reconstruction' below.)

●As an alternative to the last two steps, the distal esophagus may be divided with a GIA stapler, and the anvil of the EEA stapler can be introduced across the GIA staple line via a specialized nasogastric tube introduced orally (eg, OrVil device). In this instance, stay sutures may be omitted. A handsewn anastomosis is technically more difficult and therefore only done rarely when a stapled anastomosis is not feasible [41].

Gastrointestinal reconstruction — The optimal method of reconstruction after total gastrectomy would provide for a functional reservoir, preserve duodenal and jejunal continuity, and minimize postgastrectomy functional disturbance [42]. No one reconstruction technique fulfills all these criteria; however, Roux-en-Y esophagojejunostomy with a jejunal pouch appears to have better functional outcomes and improved quality of life compared with other types of reconstruction in the short term [43-49].

Reconstruction options — The most commonly performed gastrointestinal reconstructive procedure after a total gastrectomy is Roux-en-Y esophagojejunostomy with or without a jejunal pouch. Less commonly performed procedures include jejunal interposition, colon interposition, and looped esophagojejunal anastomosis [42].

●Roux-en-Y esophagojejunostomy – After total gastrectomy, a direct esophagus-to-duodenum anastomosis (Billroth I) is anatomically difficult. A loop esophagojejunostomy (Billroth II) is rarely performed because of bile reflux. Thus, Roux-en-Y esophagojejunostomy (figure 10) is the preferred reconstruction after total gastrectomy [50]. The Roux limb can be positioned antecolic or retrocolic (through transverse mesocolon) but needs to be sufficiently long (about 50 cm) to prevent bile reflux [51].

●Jejunal pouch – The loss of the gastric reservoir is an important reason that patients lose about 10 percent of their body weight over the first three to six months [42]. The gastric reservoir lost to total gastrectomy is most often replaced during reconstruction with a jejunal pouch. The benefit of jejunal pouches are most pronounced during the early postoperative months, when they increase food intake; the advantage over simple reconstruction diminishes over time, yet patients still report a better quality of life with the pouch [42,50].

A meta-analysis pooled the outcomes of 17 randomized trials and 8 observational studies involving 1621 participants and associated jejunal pouch reconstruction with a significantly decreased incidence of esophagitis and heartburn (6 versus 16 percent), dumping syndrome (5 versus 26 percent), and food intake disturbance (14 versus 44 percent) at one to two years [43]. Albumin levels and body mass index were also higher among pouch patients in the same time frame. Pouch reconstruction increased operation time slightly (259 versus 236 minutes) but did not increase morbidity or mortality or length of hospital stay.

Jejunal pouches vary in size (5 to 20 cm), configuration (J, omega, S), and location (proximal or distal). Jejunal pouches can be added to both Roux-en-Y reconstruction and jejunal interposition. The choice of a particular type of pouch is determined by surgeon preference [49].

●Other reconstruction options – Jejunal interposition and ileocolonic interposition have been studied in the past but have fallen out of favor due to lack of evidence of benefit.

•A jejunal interposition preserves the anterograde duodenal transit, which is more physiological and in theory could improve postoperative nutrition. However, a number of older trials [42] and contemporary studies [50] fail to demonstrate any advantage for jejunal interposition in weight loss or quality of life. Jejunal interposition is also associated with the disadvantages of longer operative time (by 15 to 40 minutes), the risk of an additional anastomosis, and potential for greater bile reflux or becoming involved in cancer recurrence [49].

•An ileocolonic interposition reconstructs the alimentary tract after total gastrectomy by placing a pedicled ileocecal interposition graft between the esophagus and the duodenum [52]. It does have the disadvantage of an additional colonic anastomosis [53]. It has not been compared with other methods of reconstruction in randomized trials

Roux-en-Y esophagojejunostomy with Hunt-Lawrence pouch — We prefer to use a Hunt-Lawrence type pouch with a Roux-en-Y reconstruction (figure 11):

●Transect the jejunum distal to the ligament of Treitz. Bring the jejunal loop anterior to the colon up to the esophagus.

●Fold the jejunum back onto itself, placing traction sutures along the antimesenteric border of the jejunum to hold the limbs together. The optimal length of the pouch has not been well studied. One small trial found that 13 patients with a 9 cm pouch were better able to eat at their preoperative intake level and maintain body weight compared with 14 patients who had a 12 cm pouch [54]. We make the pouch approximately 10 cm. Pouches that are too long may lead to distension, elongation, or blind loop syndrome.

●Make an incision in each loop caudally, and fire a GIA stapling device to create a side-to-side anastomosis.

●Use an EEA circular stapling device to create the anastomosis between the pouch and the esophagus. Introduce the long arm of the EEA stapler through the pouch, open the stapler to push the center post through the proximal pouch, using a scalpel or electrocautery to complete the opening. Place a pursestring suture around the pin, and pull to snug the tissue around the post. Connect the posts of the long arm and anvil of the EEA device. Close the device, firmly apposing the esophageal and jejunal tissue, and fire. Gently pull the EEA anvil through the anastomosis and remove the device from the pouch.

●Close the caudal pouch opening transversely using a TA or GIA stapling device.

●Anastomose the proximal jejunum to the efferent limb of the pouch in an end-to-side fashion 20 cm distal to the caudal end of the pouch. We generally fashion a stapled anastomosis, but a handsewn technique can also be used; either option is equally effective.

●We do not place a nasojejunal tube through the anastomoses. Modern enhanced recovery after surgery (ERAS) protocols do not call for routine use of nasogastric or nasojejunal tubes after gastric surgery [3].

Feeding jejunostomy — A jejunal feeding tube may be placed approximately 20 cm distal to the Roux-en-Y jejuno-jejunostomy in patients with preoperative weight loss or other risk factors for complicated or delayed recovery. We create a Stamm-type jejunostomy using a 14 Fr T-tube, secured with a double pursestring (3-0 absorbable suture) and anchored to the anterior abdominal wall (figure 12).

The feeding tube provides enteral access for early enteral feeding, as well as delivery of enterally administered medications in the postoperative period, and can be used for prolonged access in those who develop complications. The routine use of jejunal feeding tubes, however, is controversial since there are conflicting data as to whether it increases or decreases the morbidity of the procedure [55-57]. Contemporary ERAS protocols do not support their use, but they can be considered in select cases where patients may be at elevated risk of postoperative eating challenges. (See 'Perioperative nutritional support' below.)

POSTOPERATIVE MANAGEMENT AND FOLLOW-UP

Perioperative nutritional support — Patients are initially maintained on intravenous fluids and are not given anything to eat by mouth (ie, nil per os [NPO]). If a jejunostomy tube is placed during the operation, then this allows for early postoperative enteral feeding while the patient is NPO. Tube feeding can be initiated two to three days postoperatively and advanced according to the patient's tolerance. The presence of a postoperative ileus may limit the tolerance to tube feeding, particularly in the first days after surgery. (See "Overview of perioperative nutrition support", section on 'Early enteral feeding'.)

We obtain a Gastrografin swallowing study between postoperative days three and five to evaluate the esophagojejunal anastomosis for leak prior to initiating an oral diet. However, practices vary, and there is some evidence that an oral diet may be initiated as early as the first postoperative day after a total gastrectomy [3]. Obviously, the initiation of oral diet would be influenced by the overall condition of the patient, chronic comorbidities, and how well the operation went.

In the absence of anastomotic leak on Gastrografin swallow, we start a liquid diet and advance to a soft diet over 24 to 48 hours. Small, frequent meals, high in protein and inclusive of fat, should be consumed approximately six times per day. Liquids may need to be taken separately from solids. Meals high in simple carbohydrates may contribute to dumping syndrome and may need to be avoided. (See "Postgastrectomy complications", section on 'Dumping syndrome'.)

Alteration in dietary intake and weight loss are to be anticipated with this procedure. Close involvement with a dietitian familiar with postgastrectomy patients is advisable to help patients adjust to their new dietary regimen and minimize weight loss. Vitamin and mineral supplementation are also required.

Follow-up — Schedules of follow-up after total gastrectomy vary by indication. The suggested postgastrectomy surveillance for gastric cancer is presented in another topic. (See "Surgical management of invasive gastric cancer", section on 'Post-treatment surveillance'.)

Routine surveillance endoscopy is not necessary. Endoscopy is appropriate when symptoms warrant investigation. Locoregional recurrence of adenocarcinoma in the setting of total gastrectomy is almost universally fatal, and there is no evidence that early detection of recurrence prolongs life.

PERIOPERATIVE MORBIDITY AND MORTALITY — The risk of perioperative death from gastrectomy is associated with patient age and extent of lymph node dissection. Patient nutritional status and neoadjuvant therapy may also be a factor. In contemporary series, perioperative mortality rates range from 2 to 4 percent [58,59].

Perioperative morbidity rate ranges from 21 to 44 percent, depending on the length of follow-up and the definition of morbidities [58,59]. Perioperative surgical complications following total gastrectomy are primarily due to the consequences of anastomotic leak. Long-term surgical complications include late esophageal stricture and postgastrectomy syndromes.

Anastomotic complications — Disruption of the esophagojejunal anastomosis is the most worrisome complication in the early postoperative period. The jejunojejunal anastomosis is rarely a problem. Various groups have reported esophageal leak rates of 5 to 7 percent [59,60]. Minor leaks without systemic sepsis can be managed conservatively with antibiotics, intestinal decompression, and percutaneous drainage of any associated fluid collections or abscess. Intestinal decompression in the absence of the stomach is accomplished using a nasojejunal tube placed distal to the esophageal anastomosis, typically using fluoroscopic guidance. A covered stent across the anastomosis may also be applied with good effect [61].

Major disruption that requires reoperation is fraught with difficulties and is associated with increased mortality. Overall, disruption of the esophagojejunal anastomosis is associated with poorer survival (hazard ratio 3.47, 95% CI 1.82-6.64) [62]. The occurrence of anastomotic leak also increases the risk for subsequent anastomotic stricture.

Stricture of the esophagojejunostomy is reported in approximately 4 percent of patients [63]. The rate of stricture can be affected by the anastomotic technique (eg, handsewn versus stapled; end-to-end anastomosis stapler versus linear stapler) [64-66], but there is no conclusive evidence that one technique is superior to others. Patients with anastomotic stricture will usually present with dysphagia. Upper endoscopy can diagnose the stricture, which can be also be dilated endoscopically, usually with good results; however, repeated sessions may be needed.

Postgastrectomy syndromes — A 10 to 15 percent decrease in body weight and postgastrectomy syndromes are common sequelae of total gastrectomy [2,67,68]. The dumping syndrome and diarrhea are most severe in the initial postoperative period and generally improve within 12 months [69]. Postgastrectomy complications are discussed in detail in another topic. (See "Postgastrectomy complications".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Gastric surgery for cancer".)

SUMMARY AND RECOMMENDATIONS

●Indications and contraindications for total gastrectomy – The term "total gastrectomy" implies the complete removal of all gastric tissue. Total gastrectomy is the treatment of choice for certain malignancies of the proximal stomach, diffuse signet ring gastric adenocarcinoma, and hereditary diffuse gastric cancer (cadherin-1 [CDH1] mutation), both in the prophylactic setting and when invasive gastric cancer has been confirmed. Benign indications for total gastrectomy are rare but may include hemorrhagic gastritis and intractable symptoms in patients who have undergone prior partial gastrectomy. Metastatic disease and severe medical comorbidities contraindicate total gastrectomy. (See 'Indications' above and 'Contraindications' above.)

●Preoperative staging – Patients undergoing total gastrectomy for malignancy should undergo preoperative staging to rule out metastatic disease, including computed tomography (CT) of the abdomen and upper endoscopy. Staging laparoscopy may be indicated for patients with locally advanced gastric adenocarcinoma. (See 'Tumor staging' above and "Surgical management of invasive gastric cancer", section on 'Staging evaluation'.)

●Surgical prophylaxis

•Prophylactic antibiotics – All patients undergoing total gastrectomy should receive intravenous antibiotic prophylaxis (table 1). Mechanical bowel preparation is not necessary. (See 'Antibiotics' above.)

•Thromboprophylaxis – All patients undergoing total gastrectomy for malignancy should receive pharmacologic prophylaxis and mechanical prophylaxis with intermittent pneumatic compression. (See 'Thromboprophylaxis' above.)

●Procedure – Total gastrectomy is accomplished by exposing and isolating the stomach, dividing the esophagus and proximal duodenum, removing the specimen, and then restoring gastrointestinal continuity. (See 'Procedure' above.)

•Margins – For most patients undergoing total gastrectomy, we obtain intraoperative frozen sections of the proximal and/or distal margins. For adenocarcinoma, the margins should be clear of tumor. For patients undergoing prophylactic gastrectomy, the proximal margin should be clear of gastric mucosa. (See 'Margins of resection' above.)

•Lymphadenectomy – For patients undergoing total gastrectomy for gastric adenocarcinoma or carcinoid, we suggest a D2 lymphadenectomy without splenectomy, rather than a lesser (D1) or greater amount (D3) (Grade 2C). For patients undergoing prophylactic gastrectomy for CDH1 mutation, gastrointestinal stromal tumors (GISTs), or the rare instance of total gastrectomy for benign reasons, formal lymphadenectomy is not needed. (See 'Extent of nodal dissection' above and "Surgical management of invasive gastric cancer", section on 'Extent of lymph node dissection'.)

•Vagus nerve sparing – Whenever possible, we suggest preserving the hepatic branch of the anterior vagus nerve and the celiac branch of the posterior vagus nerve, rather than sacrificing these nerves with the specimen (Grade 2C). Vagus nerve preservation minimizes the incidence of gallstone formation and diarrhea, which can occur in patients who undergo truncal vagotomy. (See 'Vagus nerve preservation' above.)

•Reconstruction – After total gastrectomy, we suggest an esophagojejunostomy with a jejunal pouch reconstruction rather than other reconstructive methods (Grade 2B). Jejunal pouch reconstruction improves postoperative quality of life. We prefer the Hunt-Lawrence type of jejunal pouch, but the pouch size and design are surgeon preference. (See 'Gastrointestinal reconstruction' above.)

●Postoperative care – Postoperatively, the patient is maintained on intravenous fluids. Oral and enteral feeding can be introduced postoperatively in a tailored fashion depending on whether an enhanced recovery after surgery (ERAS) protocol is followed and upper gastrointestinal contrast study is obtained, and whether a jejunal feeding tube has been placed. (See 'Postoperative management and follow-up' above.)

●Outcomes – Perioperative mortality rates following total gastrectomy range between 2 and 4 percent, depending upon patient age and extent of lymph node dissection. Perioperative surgical complications following total gastrectomy are primarily due to the consequences of anastomotic leak, which occurs in 5 to 7 percent of patients. Long-term surgical complications include late esophageal stricture and postgastrectomy syndromes. (See 'Perioperative morbidity and mortality' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Debrah Wirtzfeld, MD, MSc, FRCSC, FACS, who contributed to an earlier version of this topic review.