A gastrectomy is a partial or total surgical removal of the

stomach The stomach is a muscular, hollow organ in the upper gastrointestinal tract of Human, humans and many other animals, including several invertebrates. The Ancient Greek name for the stomach is ''gaster'' which is used as ''gastric'' in medical t ...

Indications

Gastrectomies are performed to treat

stomach cancer Stomach cancer, also known as gastric cancer, is a malignant tumor of the stomach. It is a cancer that develops in the Gastric mucosa, lining of the stomach. Most cases of stomach cancers are gastric carcinomas, which can be divided into a numb ...

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. For severe

duodenal ulcer Peptic ulcer disease is when the inner part of the stomach's gastric mucosa (lining of the stomach), the first part of the small intestine, or sometimes the lower esophagus, gets damaged. An ulcer in the stomach is called a gastric ulcer, while ...

s, it may be necessary to remove the lower portion of the stomach and the upper portion of the small intestine. 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

common bile duct The common bile duct (also bile duct) is a part of the biliary tract. It is formed by the union of the common hepatic duct and cystic duct. It ends by uniting with the pancreatic duct to form the ampulla of Vater (hepatopancreatic ampulla). ...

. If the stomach cannot be reattached to the duodenum, a Billroth II is performed, wherein 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 specialized for the absorption by enterocytes of small nutrient molecules which have been pr ...

), 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.

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 and Friedrich Paul Reichel. It involves a resection of 2/3 of the

with blind closure of the duodenal stump, and a retrocolic gastrojejunostomy.

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 gastric dumping syndrome. 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 o ...

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 (also spelt anaemia in British English) is a blood disorder in which the blood has a reduced ability to carry oxygen. This can be due to a lower than normal number of red blood cells, a reduction in the amount of hemoglobin availab ...

known as megaloblastic anaemia (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. This may result in megaloblastic anemia in which red blood cells become abnormally large, and folate deficiency anemia is the term given ...

, or

autoimmune disease An autoimmune disease is a condition that results from an anomalous response of the adaptive immune system, wherein it mistakenly targets and attacks healthy, functioning parts of the body as if they were foreign organisms. It is estimated tha ...

where it is specifically known as pernicious anaemia) which severely reduces red-blood cell synthesis (known as

erythropoiesis Erythropoiesis (from Greek ''erythro'', meaning ''red'' and ''poiesis'', meaning ''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 s ...

, as well as other haematological cell lineages 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 ( ...

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 primarily 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 ghrel ...

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; it has 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 it ...

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

peptic ulcer Peptic ulcer disease is when the inner part of the stomach's gastric mucosa (lining of the stomach), the first part of the small intestine, or sometimes the lower esophagus, gets damaged. An ulcer in the stomach is called a gastric ulcer, while ...

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 pathogenic bacteria, bacterial infections, and antibiotic medications are widely used in the therapy ...

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

Helicobacter pylori ''Helicobacter pylori'', previously known as ''Campylobacter pylori'', is a gram-negative, Flagellum#bacterial, flagellated, Bacterial cellular morphologies#Helical, helical bacterium. Mutants can have a rod or curved rod shape that exhibits l ...

'' infection or chemical imbalances in the gastric juices. In the past a gastrectomy for peptic ulcer disease was often accompanied by a vagotomy, 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. The body eventually synthesizes ne ...

References

External links