By Jennifer Whitlock, RN, MSN, FN
Medically reviewed by Robert Burakoff, MD
Gastrectomy is the surgical removal of all or part of the stomach. This abdominal operation is used to treat certain stomach-related conditions, including ulcers that do not improve with conservative therapies and stomach (gastric) cancer. A special type of gastrectomy, called a sleeve gastrectomy, is used to treat individuals with obesity.
What Is a Gastrectomy?
A gastrectomy is performed by a general surgeon, surgical oncologist, or a bariatric surgeon in a hospital under general anesthesia.
The surgery is usually scheduled in advance. Less commonly, with stomach trauma or complications related to ulcer disease (e.g., bleeding or perforation), gastrectomy may be performed emergently.1
Types
Your stomach is a J-shaped organ located in the upper abdomen that plays a key role in initiating digestion. Removing the stomach or a portion of it, therefore, affects how efficiently food starts to break down, as well as how quickly it moves into the small intestines.
There are three main types of gastrectomy:
Partial (subtotal) gastrectomy: A portion of the stomach is removed, most commonly the distal part of the stomach called the antrum. The remaining stomach is then reconnected to the small intestines. Proximal (upper) gastrectomies are less commonly performed and may involve different reconstruction techniques, one being to create a surgical connection between the esophagus and the stomach remnant.2
Total gastrectomy: The entire stomach is removed, requiring that the patient's esophagus be surgically connected to the small intestines (either the first or middle part, called the duodenum and jejunum, respectively).
Sleeve gastrectomy: This bariatric (weight loss) surgery entails dividing the stomach vertically and creating a tubular-shaped stomach; about 85% of the stomach is removed.3 No reconstruction is needed, as the connection between the stomach and the esophagus/small intestines remains intact. Weight loss occurs as a result of restriction in food consumption and absorption.
Surgical Approaches
A partial or total gastrectomy can be performed as an open surgery or laparoscopically.
Open: With this approach, the stomach is removed through a single large incision made in the abdomen.
Laparoscopic: With this minimally invasive approach, multiple tiny incisions are made in the abdomen. A tool that has a camera attached to it, called a laparoscope, is inserted into one of the incisions. This tool allows the surgeon to visualize the stomach through images projected onto a monitor. Other surgical tools are inserted through the other incisions to remove the stomach or a part of it.
Laparoscopic gastrectomy may offer some advantages over open surgery including:4
Less blood loss during the operation
Less pain after surgery
Earlier return to normal bowel function
Earlier discharge from the hospital
Sleeve gastrectomy is frequently performed laparoscopically, although it can be performed as an open surgical procedure. Compared with open bariatric surgery, laparoscopic bariatric surgery is associated with a lower risk of wound infection and incisional hernia (two potential surgical complications).5
Contraindications
The contraindications for surgery vary based on the type of gastrectomy being performed.
Partial Gastrectomy
Absolute contraindications to partial gastrectomy include:6
Suspected or diagnosed hereditary diffuse gastric cancer (an inherited disorder)
Widespread (metastatic) stomach cancer, unless cancer-related complications (e.g., obstruction, bleeding, or perforation) cannot be treated with non-surgical means
Ulcer disease at the antrum is a relative contraindication, as it is associated with inflammation of the pylorus, a valve that allows stomach contents to empty into the small intestines.6
Total Gastrectomy
Absolute contraindications to total gastrectomy include:7
Widespread (metastatic) gastric cancer with little to no symptoms
Negative margins can be achieved with a partial gastrectomy for gastric cancer
Relative contraindications to total gastrectomy include:7
Having significant underlying health conditions, especially heart or lung disease
Being malnourished
Sleeve Gastrectomy
Absolute contraindications to sleeve gastrectomy include:
Severe, uncontrolled mental health illness (e.g., an eating disorder)
An underlying bleeding disorder
Relative contraindications to sleeve gastrectomy include:8
Barrett's esophagus
Uncontrolled severe gastroesophageal reflux disease (GERD)
A large hiatal hernia
Potential Risks
In addition to the known risks of anesthesia and the general risks of all abdominal surgeries (e.g., bleeding, infection, and wound dehiscence), gastrectomy is associated with these specific risks:9
Marginal ulcer: A marginal ulcer, which resembles a peptic ulcer, may form around the site where the stomach is reconnected to the small intestines following a partial gastrectomy. 10
Stricture: A narrowing at a surgical connection site due to scar tissue (anastomosis) may result in gastric outlet obstruction associated with bloating and vomiting.
Gastric leak: A leak of digestive juice and partially digested food into the abdominal cavity may occur along any staple or suture line.
Dumping syndrome: Dumping syndrome occurs when sugars/simple carbohydrates move too rapidly from the stomach into the upper part of the small intestines, leading to symptoms like cramping, diarrhea, feeling faint, cold sweats, nausea, and bloating.
Small bowel obstruction: A blockage in the small intestines may occur for a number of reasons (e.g., internal hernia, scar tissue, bowel kinking). It may cause symptoms like nausea, vomiting, early satiety (feeling of fullness), and/or upper abdominal pain.11
Nutritional deficiencies: A decrease in food absorption may cause various vitamin and mineral deficiencies (e.g., deficiency in iron or vitamin B12).
GERD: Distortion of the esophageal/stomach anatomy after a gastrectomy may result in heartburn.
Weight regain (after a sleeve gastrectomy): Regaining weight that was initially lost after surgery may be due to poor eating habits or widening of the remnant stomach pouch.12
Purpose of Gastrectomy
A gastrectomy may be indicated for a number of medical conditions, and the diagnosis will dictate the type of surgery that is performed.
The purpose of a partial or total gastrectomy is to treat health conditions that affect the stomach, such as:
Ulcer disease: A partial gastrectomy is the last resort choice of treatment for ulcers when conservative measures—such as taking a proton pump inhibitor (PPI) along with antibiotics to eradicate Helicobacter pylori, a bacteria linked to ulcer formation—have failed. A partial gastrectomy may also be indicated for complications related to ulcer disease, including bleeding, perforation (a hole) within the stomach wall, or gastric outlet obstruction.
Gastric cancer: Depending on the type and stage of cancer, a partial or total gastrectomy may be performed. Nearby lymph nodes and organs (e.g., esophagus or the upper part of the small intestines) may also be removed during the same surgery.13
Benign growths: Noncancerous growths of the stomach may warrant a gastrectomy (usually partial).
Trauma: Injury to the stomach requires an emergent gastrectomy (usually partial).
The purpose of a sleeve gastrectomy is to help obese individuals lose weight and improve/reverse obesity-related conditions (e.g., diabetes).
The indications for undergoing sleeve gastrectomy include:
Body mass index (BMI) greater than or equal to 40
BMI over 35 with one or more obesity-related health conditions
BMI over 30 with uncontrollable type 2 diabetes or metabolic syndrome
BMI is a dated, flawed measure. It does not take into account factors such as body composition, ethnicity, sex, race, and age.
Even though it is a biased measure, BMI is still widely used in the medical community because it’s an inexpensive and quick way to analyze a person’s potential health status and outcomes.
Keep in mind: Since sleeve gastrectomy requires a lifelong commitment to post-operative dietary changes, in addition to meeting the above criteria, patients must undergo several pre-surgical tests and assessments to ensure they are mentally, physically, and cognitively ready for the surgery.14
Some of these tests may include:
Blood tests, such as a complete blood count (CBC) and hemoglobin A1C
Studies, such as an electrocardiogram (ECG), overnight sleep study, an esophagogastroduodenoscopy (EGD), and abdominal ultrasound15
A nutritional evaluation
How to Prepare
Once you are cleared for surgery and your operation date is scheduled, your surgeon will give you instructions on how to prepare, including:
Stopping certain over-the-counter or prescription medications (e.g., nonsteroidal anti-inflammatory drugs)
Stopping smoking and drinking alcohol
As the surgery day approaches, your surgeon may ask you to:
Adhere to a clear liquid diet starting the day before surgery
Shower with a special antiseptic solution on the eve before your surgery
Avoid any liquids, including water, starting two hours prior to your scheduled arrival time for surgery
Pack personal items you will need for your hospital stay
In addition to the above preparatory steps, if you are undergoing sleeve gastrectomy, your surgeon may recommend the following:
Participating in several bariatric pre-surgical lifestyle classes16
Consuming a liquid-only diet for one to two weeks before your surgery: This may depend on factors like your BMI going into surgery and your surgeon's preference.17
What to Expect on the Day of Surgery
On the day of your operation, you will first go to a pre-operative room where you will change into a hospital gown. A nurse will then record your vitals, place an IV in your arm or hand, and administer an antibiotic.
When the surgical team is ready, you will be wheeled into the operating room. An anesthesiologist will give you medications to put you to sleep and then insert a breathing tube connected to a ventilator. Inflatable compression devices will also be placed around your legs to help prevent blood clots.
A gastrectomy generally proceeds in the following fashion:
After the skin is cleaned, the surgeon will make a large abdominal incision (open surgery) or make multiple, tiny abdominal incisions (laparoscopic surgery).
Next, the surgeon will remove a portion of the stomach (partial or sleeve gastrectomy) or all of the stomach (total gastrectomy).
Depending on the underlying diagnosis, other tissues may be removed during a partial or total gastrectomy (e.g., lymph nodes, all or part of the duodenum, etc.)
Various reconstruction techniques may then be performed, depending on the type of gastrectomy being done. For example, for a partial gastrectomy of the distal stomach, the remaining portion will be reattached to the small intestines.
Any tissue incision lines will be closed and carefully checked to make sure they are not leaking.
The abdomen will then be closed with staples or absorbable sutures.
Anesthesia will be stopped, the breathing tube will be removed, and you will be taken to a recovery room where you will wake up.
Operation Time
Since reconnection to the small intestines or esophagus is required, a partial or total gastrectomy may take up to five hours. A sleeve gastrectomy generally takes one to two hours.18
Recovery
Once you wake up in the recovery room, a nurse will be present to monitor your vital signs and give you medications for any common post-operative symptoms you may be experiencing, like pain or nausea. After a few hours in the recovery room, you will be moved to a hospital room.
The duration of your hospital stay will depend on the type of gastrectomy performed and the surgical approach used. Generally speaking, you can expect to stay about one to two nights if you undergo a sleeve gastrectomy and around seven nights if you have a partial or total gastrectomy.19
In your hospital room, you will be closely monitored for complications (e.g., bleeding and infection). You will also be encouraged to get out of bed and start walking around to prevent blood clots from forming in your legs.
In terms of eating after a gastrectomy, you will start off with a clear liquid diet and slowly progress to a regular diet, as tolerated. The timing of when this happens varies. Intravenous fluids are used to keep you hydrated; in some cases, a feeding tube may be placed to provide nutrition.7
When eating and drinking resumes, you will need to follow your healthcare provider's guidelines. For example:
Eating five to six small and high-protein meals a day
Eating slowly and chewing thoroughly
Avoiding greasy, spicy, and sugary foods.
Take any recommended supplements as advised to prevent nutritional deficiencies.20
Your surgeon will give you additional instructions related to wound care, physical activity, and more to follow at home as well.
Long-Term Care
Partial or total gastrectomy is a major operation that may result in unpleasant symptoms, including early satiety, loss of appetite, heartburn, problems swallowing, nausea, and vomiting. While these symptoms can generally be managed with diet and lifestyle modifications, they, nevertheless, may profoundly impact quality of life.21
Sleeve gastrectomy recovery, while not as arduous or risky as with partial/total gastrectomy, still requires close follow-up and ongoing care from a surgeon and dietitian to ensure a positive surgical outcome.
To maximize your long-term recovery from gastrectomy, it's important to:
Attend all of your follow-up appointments with your surgeon and dietitian
Complete any follow-up care required
Stick with your postgastrectomy diet
Due to the magnitude of the surgery and its potential associated indications, know that it's normal to feel a roller coaster of emotions (e.g., sadness, anger, irritability) after surgery. Besides talking with loved ones, consider reaching out to a social worker, support group, or experienced therapist for emotional guidance.
Gastrectomy, especially for cancer or complicated ulcer disease, is a significant operation. Your individual recovery will depend on many factors including your age, overall health, how much of your stomach was removed, and how your digestive system was reconstructed.
During your recovery, in addition to remaining devoted to your care, remember to be kind to yourself and take one day at a time so you can optimize your healing.
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By Jennifer Whitlock, RN, MSN, FN
Jennifer Whitlock, RN, MSN, FNP-C, is a board-certified family nurse practitioner. She has experience in primary care and hospital medicine.
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