Chapter 6. Operative Management of Gastric Lesions

• Malignant tumors.
• Benign tumors.
• Intractable bleeding.
• Chronic ulceration and inflammation.

Absolute

• Inability to completely resect primary cancer.
• Distant metastases.

Relative

• High operative risk because of age or comorbidities.

• The patient should be supine, with the operating surgeon on the right side of the patient.
• An upper midline incision is made from the xiphoid to the umbilicus to enter the abdomen.
  • Reverse Trendelenburg positioning facilitates exposure.
• Once the abdomen has been entered, a routine exploration should be performed and a nasogastric tube placed by the anesthetist.

• Nothing by mouth.
• Monitoring for return of bowel function.
• Early nutritional support.
  • Parenteral or jejunal feedings are not routinely necessary but may be considered for delayed bowel function or delayed emptying.
  • Postgastrectomy diet (six or more small meals daily, high protein, low carbohydrate, decreased liquids with meals).

Early

• Complications from general anesthesia.
• Wound infection.
• Anastomotic leak.
• Bleeding.
• Subphrenic or intra-abdominal abscess and peritonitis.
• Early dumping syndrome.
• Acute afferent loop syndrome.
• Rupture of duodenal stump.

Late

• Late dumping syndrome.
• Obstruction.
• Marginal ulcer disease (in jejunum no more than 2 cm from gastrojejunal anastomosis).
• Pernicious anemia (caused by vitamin B12 deficiency).
• Alkaline reflux gastritis.
• Chronic afferent and efferent loop syndromes.