Gastric resection, or gastrectomy, is now performed mainly for treatment of gastric carcinoma. Benign ulcer disease, formerly a major indication, is still sometimes treated by gastrectomy, often in emergency circumstances or neglected cases. Many modifications of the operation exist, differing in the extent of resection and the method of reconstruction of gastrointestinal continuity. This chapter describes basic techniques of gastric resection and reconstruction, primarily as performed for benign disease. The chapter which follows (Chapter 62) describes gastric resection for carcinoma.

The extent of resection is determined by the pathology. An antrectomy (resection of the antrum of the stomach) is performed for peptic ulcer disease, usually with a concomitant truncal vagotomy. A subtotal gastrectomy involves resection of additional stomach and is generally quantitated according to the approximate amount removed as shown in Figure 61.1A (e.g., a 60% gastrectomy). For radical subtotal gastrectomy, which is performed for carcinoma, resection of the omentum and regional lymph nodes is added (see Chapter 62). Regional lymph nodes lie along the greater and lesser curvatures and along named blood vessels. Total gastrectomy, also generally performed for carcinoma, entails removal of the entire stomach and surrounding node-bearing tissue. The spleen may also be removed during operations for gastric cancer to resect regional lymph nodes in the splenic hilum.

The simplest method of reconstruction after partial gastrectomy is by direct anastomosis of the gastric remnant to the duodenum (Billroth I reconstruction) as shown in Figure 61.1B. This creates what morphologically resembles a small stomach and is applicable when the gastric remnant and the duodenum can be brought together without tension. It is not used in operations for gastric carcinoma because the extent of resection generally precludes it and because recurrent disease can obstruct the new outlet.

The Billroth II reconstruction (Fig. 61.1C) eliminates problems with tension after an extensive resection, as well as the potential for recurrent disease, by closing the duodenal stump and draining the gastric remnant by a gastrojejunal anastomosis. The two limbs of a Billroth II are termed the afferent limb, which drains the duodenal stump, and the efferent limb, through which food exits the stomach into the small intestine. Bile and pancreatic juice from the afferent limb continually pass the stoma and sometimes cause gastritis; the Roux-en-Y reconstruction is designed to surmount this.

In this chapter, partial or subtotal gastrectomy for benign disease is presented first with discussion of the Billroth I and Billroth II methods of reconstruction. Radical subtotal gastrectomy and total gastrectomy are discussed in the chapter which follows (Chapter 62). Less common procedures (rarely performed at present), such as proximal gastric resection, are discussed in the references at the end of the chapter.