Gastrectomy for Cancer
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Direct answer
D2 lymphadenectomy is the technical heart of curative gastric surgery: distal tumours take a distal gastrectomy, proximal and extensive tumours a total gastrectomy, each with omentectomy and clearance of nodes along the left gastric, common hepatic, coeliac and splenic arteries plus the hepatoduodenal ligament, aiming for at least fifteen nodes. Perioperative FLOT chemotherapy now wraps around resection for locally advanced adenocarcinoma, and staging laparoscopy with peritoneal cytology precedes any laparotomy, because radiologically occult peritoneal disease is found in a meaningful minority. Reconstruction is Roux-en-Y in modern practice, and lifelong surveillance for iron, vitamin B12 and bone disease is part of the operation, not an afterthought.
What you must remember
- D2 content: nodes along the left gastric (station 7), common hepatic (8), coeliac (9), splenic hilum and artery (10, 11) and hepatoduodenal ligament (12), with greater and lesser omentectomy.
- Spleen and pancreas tail are preserved unless directly involved — routine splenectomy adds morbidity without survival (the lesson of the Dutch and JCOG trials); splenectomy is reserved for greater-curve or cardia tumours involving the hilum.
- Node count: fifteen or more examined nodes constitute adequate staging; fewer reflects inadequate dissection or host factors.
- Margins: about 5 cm of gross stomach beyond the tumour with intraoperative frozen section — proximal oesophageal margin matters most in total gastrectomy.
- Perioperative FLOT (5-fluorouracil, folinic acid, oxaliplatin, docetaxel) improved five-year survival to about 45 per cent versus 36 per cent with older perioperative regimens in the FLOT4 trial.
- Staging laparoscopy with peritoneal washings detects occult peritoneal and hepatic-surface disease; positive cytology is M1 and changes everything.
- Reconstruction: Roux-en-Y after both total (oesophagojejunostomy) and distal gastrectomy — it diverts bile from the remnant better than Billroth II.
- Post-gastrectomy syndromes: early and late dumping, afferent loop obstruction (Billroth II), alkaline reflux gastritis, iron and B12 deficiency anaemia, folate deficiency, and metabolic bone disease.
- Early gastric cancer: endoscopic submucosal dissection for intestinal-type mucosal cancers within expanded criteria (differentiated, ≤2 cm, ulcer-free); otherwise D1+ resection suffices.
A worked case: antral adenocarcinoma
A 60-year-old man has three months of post-prandial fullness and weight loss; endoscopy shows an antral ulcerating tumour with moderately differentiated adenocarcinoma on biopsy, and CT stages it cT2N0 without metastases. Staging laparoscopy with peritoneal washings is performed first — a step candidates forget — and is negative. Perioperative FLOT precedes surgery in this locally advanced setting. At operation: distal gastrectomy with 5 cm margins confirmed by frozen section, D2 lymphadenectomy sparing spleen and pancreas, and Roux-en-Y reconstruction; a feeding jejunostomy is placed selectively. Histology returns pT2N0 with 22 nodes examined — the number that proves the dissection. Post-operatively the conversation is nutritional: small frequent meals, lifelong parenteral vitamin B12 (quarterly), iron and calcium monitoring, and graded return of oral intake as gastric remnant tone recovers. Dumping symptoms in the first months are managed with dietary manipulation — separating liquids from solids, limiting simple sugars — before any pharmacological escalation.
How the examiner frames it
Three questions separate candidates. "What is in a D2 dissection?" — name the arterial stations, not the word "radical". "Will you remove the spleen?" — no, unless involved; quote the morbidity lesson. "Why laparoscope before opening?" — occult peritoneal disease and cytology. The post-gastrectomy syndromes are then tested as a mismatch game: afferent loop obstruction belongs to Billroth II, bilious vomiting after a Roux-en-Y suggests a construction error rather than routine reflux, and a B12-deficient patient two years after total gastrectomy who never received supplements is a systems failure the viva will name.
Frequently asked questions
What does a D2 lymphadenectomy include?
Nodal clearance along the left gastric, common hepatic, coeliac and splenic arteries with the hepatoduodenal ligament nodes, together with greater and lesser omentectomy — at least fifteen nodes examined.
Why is the spleen preserved during D2 gastrectomy?
Routine splenectomy and distal pancreatectomy increased morbidity and mortality without survival benefit; splenectomy is reserved for tumours directly involving the splenic hilum.
Why perform staging laparoscopy before gastrectomy?
Radiologically occult peritoneal deposits and positive peritoneal cytology (which upstages to M1) are found in a proportion of apparently localised cancers, avoiding a futile laparotomy.
Which early gastric cancers can be treated endoscopically?
Differentiated, intestinal-type mucosal cancers without ulceration — classically within 2 cm for absolute criteria — are cured by endoscopic submucosal dissection in expert centres.
What does FLOT add around gastric cancer surgery?
Docetaxel added to 5-fluorouracil, folinic acid and oxaliplatin perioperatively improved five-year survival to about 45 per cent from 36 per cent in FLOT4, making it the reference perioperative regimen.
What nutritional surveillance follows total gastrectomy?
Lifelong parenteral vitamin B12, monitoring of iron and folate with replacement, calcium and vitamin D for bone health, and dietary management of dumping and early satiety.