Open Gastric Surgery for Gastric Cancer PDF

O p e n G a s t r i c Su r g e r y f o r Gastric Cancer Allen T. Yu, MD, PhD, Elad Sarfaty, MD, Maranda Pahlkotter, MD, Noah A. Cohen, MD* KEYWORDS  Open surgical resection  Gastric cancer  Open total gastrectomy  Open subtotal gastrectomy ...

O p e n G a s t r i c Su r g e r y f o r Gastric Cancer Allen T. Yu, MD, PhD, Elad Sarfaty, MD, Maranda Pahlkotter, MD, Noah A. Cohen, MD* KEYWORDS  Open surgical resection  Gastric cancer  Open total gastrectomy  Open subtotal gastrectomy  Open proximal gastrectomy KEY POINTS  Open gastrectomy is recommended for resection of bulky gastric tumors, gastric tumors invading surrounding organs, and tumors with extensive lymphadenopathy.  A total gastrectomy is the gold standard for tumor resection that is not amenable to a distal or proximal gastrectomy.  Current guidelines require at least 16 lymph nodes are needed for appropriate staging.  Subtotal gastrectomy has multiple reconstruction options, and offers similar oncologic outcomes and superior nutritional benefits compared to a total gastrectomy.  Proximal gastrectomy has similar outcomes and recurrence rates as total gastrectomy and may confer some nutritional benefits, but is technically more challenging. INTRODUCTION Gastric cancer is a rare malignancy in the United States. However, it is a leading cause of cancer and cancer-related mortality worldwide, especially in East Asia. Due to a lack of a comprehensive screening program in the United States, and non-specific symptoms, gastric cancer is often diagnosed at an advanced stage, which carries a poor prognosis. Accurate clinical staging is essential to guide the optimal manage- ment of gastric cancer. For patients with early-stage gastric cancer, surgical resection or, in highly-selected cases, endoscopic resection may be sufficient treatment. For patients with locally advanced gastric cancer, a combination of systemic therapy and surgical resection is recommended. Patients with advanced gastric cancer typi- cally receive systemic therapy and best supportive care. For patients undergoing sur- gical resection, open resection with a perigastric lymphadenectomy is the standard Division of Surgical Oncology, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA * Corresponding author. Division of Surgical Oncology, Department of Surgery, Icahn School of Medicine at Mount Sinai, 1212 Fifth Avenue, New York, NY 10029. E-mail address: [email protected] Surg Clin N Am 105 (2025) 1–13 https://doi.org/10.1016/j.suc.2024.06.002 surgical.theclinics.com 0039-6109/25/ª 2024 Elsevier Inc. All rights are reserved, including those for text and data mining, AI training, and similar technologies. Descargado para Anonymous User (n/a) en University of the Americas de ClinicalKey.es por Elsevier en diciembre 11, 2024. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2024. Elsevier Inc. Todos los derechos reservados. 2 Yu et al treatment in the United States; however, there are data to support a more extensive lymphadenectomy and the use of minimally invasive techniques. Here, the authors present an overview of gastric cancer, diagnosis and staging, and open approaches to gastric resection. BACKGROUND Comprising more than 90% of all gastric neoplasms, adenocarcinomas are by far the most common gastric malignancy, while other gastric malignancies, such as lym- phoma, neuroendocrine tumors, and sarcoma, are rare. Gastric cancer constitutes 1.4% of newly diagnosed cancer cases in the United States, ranking as the 15th most common malignancy. Worldwide, gastric cancer is the fifth most commonly diagnosed cancer and the fourth leading cause of cancer-related mortality in 2020. Gastric cancer exhibits, on average, a 2-fold male preponderance in new cases, and is most prevalent in Eastern Asia, where the incidence is up to 3 times higher than the global average. In recent years, there has been a marked global increase in the incidence of gastric cancer in young adults.1 When considering gastric cancer prevalence, it is essential to distinguish between 2 distinct entities: proximal gastric (cardia) and distal gastric. These regions differ in many aspects, including epidemiologic patterns, risk factors, and mechanism of carci- nogenesis. While the vast majority of non-cardia gastric cancer is attributable to Hpy- lori infection, the risk factors for proximal gastric cancer are more similar to those for esophageal cancer. They include, among others, tobacco smoking, alcohol use, gastroesophageal reflux, excess body weight, dietary factors, and low socioeconomic status.2,3 Gastric adenocarcinoma can be further subdivided according to the Lauren histo- logic classification system into intestinal and diffuse types. Recent efforts aim to create a more clinically useful tool, subdividing gastric cancer by molecular profiling into 4 genomic subtypes, Epstein-Barr virus-infected tumors, microsatellite instability tumors, genomically stable tumors, and chromosomally unstable tumors. This classi- fication could function as a valuable supplementary tool to histopathological analysis. These molecular subtypes exhibit distinct genomic features, offering guidance for the assessment of targeted agents in clinical trials tailored to specific populations of gastric cancer patients.4 DIAGNOSIS AND STAGING The symptoms of gastric cancer are typically vague and nonspecific, often resulting in a delayed diagnosis. These symptoms are frequently associated with more advanced lesions, manifesting as early satiety, epigastric pain, and weight loss. The origin of these symptoms can largely be attributed to either obstructing lesions or dysphagia, depending on the location of the tumor. Another important but nonspecific finding is anemia, observed in 40% of patients, indicating some degree of gastrointestinal bleeding. History and physical examination, although of limited sensitivity, will often identify advanced disease with the presence of malignant lymphadenopathy, including periumbilical (Sister Mary Joseph), supraclavicular (Virchow), and axillary (Irish) nodal disease. Additional physical examination findings include metastasis to the ovary (Krukenberg tumor), and a palpable firm shelf on rectal or vaginal examina- tion (Blumer’s shelf).5 Clinical staging guides management, and the American Joint Committee on Cancer tumor, node, metastasis (TNM) staging system is the most widely utilized staging sys- tem. The Siewert classification serves as an adjunct to guide management in proximal Descargado para Anonymous User (n/a) en University of the Americas de ClinicalKey.es por Elsevier en diciembre 11, 2024. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2024. Elsevier Inc. Todos los derechos reservados.  Open Gastric Surgery for Gastric Cancer 3 gastric and gastroesophageal junction cancers.6 Patients with Siewert I tumors, located 1 to 5 cm proximal to the gastroesophageal junction (GEJ), are managed clin- ically as esophageal cancer, while patients with Siewert III tumors, located 2 to 5 cm distal to the GEJ, are managed clinically as gastric cancer. There is considerable con- troversy for optimal management of Siewert II tumors, which are centered 1 cm prox- imal to 2 m distal to the GEJ, and ongoing trials comparing these 2 management pathways are underway.7,8 The main modalities utilized for clinical staging of gastric cancer include upper endoscopy, endoscopic ultrasound (EUS), cross-sectional im- aging including computed tomography (CT), MRI, and PET, and diagnostic laparoscopy. Flexible endoscopy is the primary modality for the preoperative assessment of gastric cancer, allowing for the collection of tissue biopsies to establish a diagnosis, facilitating tumor localization by determining its location within the stomach and tat- tooing the lesion for future identification in the operating room, and for superficial, smaller lesions, performing an endoscopic mucosal resection. Endoscopic resection may be the most accurate method of staging early gastric cancer. EUS allows for the accurate assessment of the T stage by assessing the depth of lesion invasion and provides the most precise evaluation of perigastric lymph nodes. Contrast-enhanced cross-sectional imaging of the chest, abdomen, and pelvis is used to evaluate for distant metastatic disease. MRI is more sensitive than CT for im- aging liver lesions. Combined PET/CT is more accurate in identifying occult metastatic disease and may also assist in monitoring the response to neoadjuvant treatment. The presence of ascites on cross-sectional imaging is often a poor prognostic sign, usually indicating peritoneal carcinomatosis. Laparoscopic staging is recommended for patients with potentially resectable, non- metastatic clinically staged T1b or higher.9 In a large single-center study from a West- ern center, radiographically occult metastatic disease was detected in 31% of the pa- tients.10 Staging laparoscopy should be performed prior initiating perioperative systemic therapy. ANATOMY The stomach is the most dilated portion of the digestive system. It is a large, muscular, and hollow organ, and depending on the patient’s body habitus, has a capacity of 2 L of fluid or more.11 Here, the authors outline the general anatomy of the stomach as a thorough understanding of the vascular supply and lymphatic drainage is integral to a successful gastric resection. The stomach is divided into the cardia, fundus, body, antrum, and the pylorus (Fig. 1). The esophagus connects to the stomach at the cardia, and the acute angle created between the cardia is called “the angle of His,” also known as “the esophago- gastric angle.” The lesser curvature is the medial edge of the body, and the greater curvature is the lateral edge of the stomach.12 The angular notch, or incisura, is the separation point between the body and the antrum. During eating, the proximal portion of the stomach relaxes and distends to accommodate food, while the distal portion contracts in a rhythmic fashion to aid with digestion. With each mixing wave, lasting approximately 20 seconds, the pyloric sphincter permits small food boluses into the duodenum. The 4 main layers of the stomach are the mucosa, submucosa, muscularis externa, and the serosa. The muscle tissue can be subdivided into fibers that run longi- tudinally, obliquely, and circularly along the stomach wall.13 Outside the stomach, the organ is held in place with 4 main ligaments. The gastro- colic ligament connects the greater curvature of the stomach to the transverse colon Descargado para Anonymous User (n/a) en University of the Americas de ClinicalKey.es por Elsevier en diciembre 11, 2024. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2024. Elsevier Inc. Todos los derechos reservados. 4 Yu et al Fig. 1. Anatomy of the stomach and lymph node stations. (Printed with permission from ªMount Sinai Health System.) and forms the inferior part of the anterior wall of the lesser sac. Laterally, the gastro- splenic ligament connects the greater curvature to the hilum of the spleen and con- tains the left gastroepiploic and short gastric arteries. Medially, the gastrohepatic ligament is a peritoneal attachment that connects the liver to the lesser curvature and forms the anteromedial wall of the lesser sac. This ligament contains the right and left gastric arteries. Lastly, the gastrophrenic ligament connects the diaphragm to the superior portion of the stomach and distal esophagus.14 There are very few anatomic variations of the stomach that are of surgical impor- tance. The most common variations are related to the exact position, size, and shape of the stomach, which may be related to diet. There may be organ duplication, trans- position, or diverticula, which should be apparent on cross-sectional imaging.15 Vascular Supply and Lymphatic Drainage The stomach has a rich vascular supply to sustain its high rate of mobility and disten- tion, and its high metabolic rate and continuous production of secretory factors.13 The celiac trunk, which branches directly from the aorta, provides the main arterial blood supply. The celiac trunk branches into the common hepatic, splenic, and left gastric arteries (LGA). The lesser curvature is supplied by the descending branch of the LGA, and the ascending branch supplies portions of the distal esophagus. The com- mon hepatic artery courses superior to the pancreas and the right gastric artery (RGA) typically branches off the common hepatic artery prior to the gastroduodenal artery (GDA) takeoff. The RGA runs from right to left and supplies the lesser curvature and anastomoses with the LGA. An accessory or replaced left hepatic artery arising from the LGA is a common arterial variant which can be identified on cross- sectional imaging.16 Descargado para Anonymous User (n/a) en University of the Americas de ClinicalKey.es por Elsevier en diciembre 11, 2024. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2024. Elsevier Inc. Todos los derechos reservados.  Open Gastric Surgery for Gastric Cancer 5 The left and right gastroepiploic arteries (LGEA/RGEA) are the main blood supply of the greater curvature. The LGEA branches from the splenic artery and supplies the su- perior portion of the greater curvature. There are 3 to 5 additional smaller arteries, the short gastric arteries, which branch from the splenic artery and the LGEA to supply the fundus and superior portion of the gastric body along the greater curvature. The RGEA arises from the GDA, runs along the inferior portion of the greater curvature, and finally anastomoses with the LGEA.13 Lymphatic drainage of the stomach comprises 4 levels, including 16 lymphatic sta- tions. The first level includes perigastric lymph nodes, which drain the pericardiac, lesser curvature, greater curvature, and supra/infra-pyloric lymph nodes (stations 1– 6). Level 2 lymph nodes include those that drain along the main vessels of the celiac trunk: LGA, common hepatic artery, and splenic artery (stations 7–11). A standard D1 lymphadenectomy includes level 1 nodes, and a D2 lymphadenectomy includes both level 1 and 2 nodes (see Fig. 1). Level 3 nodes include those in the hepatoduodenal ligament, posterior to the duo- denum and pancreas head, and at the root of the small bowel mesentery (stations 12– 14). Lastly, level 4 nodes are along the middle colic vein and include the para-aortic lymph nodes (stations 15–16). SURGICAL APPROACHES There are 3 main types of gastrectomy for malignancy: total gastrectomy, subtotal distal gastrectomy, and proximal gastrectomy. Selection of gastrectomy type is mainly driven by tumor location. Total gastrectomy should not be offered when wide negative margins (4–6 cm) can be achieved with a partial gastrectomy. Oncologic outcomes are similar between total and subtotal gastrectomy if a wide negative margin can be achieved with subtotal gastrectomy,17 and multiple studies have re- ported improved safety and long-term outcomes.18 However, total gastrectomy should be considered for patients with hereditary diffuse gastric cancer or CDH1 mu- tations, or in the presence of diffuse background intestinal metaplasia. Recent randomized controlled trials have compared open and minimally invasive gastrectomy, demonstrating safety and comparable oncologic outcomes. Open gas- trectomy over minimally invasive gastrectomy allows for a more adequate lymph node dissection, and no possibility of port site recurrence. Open gastrectomy is recommen- ded over minimally invasive approaches for bulky tumors, T4 tumors with direct inva- sion of surrounding organs, and for those tumors with significant lymph node involvement. For those patients with T1-T4a tumors without bulky lymphadenopathy, the Chinese Laparoscopic Gastrointestinal Surgery Study and Korean Laparoendo- scopic Gastrointestinal Surgery Study trials compared laparoscopic and open distal gastrectomy and found no difference in 5-year overall survival rates (94.2% vs 93.3%, respectively) and recurrence-free survival rates (79.5% vs 81.1%, respectively).19–21 National Comprehensive Cancer Network (NCCN) guidelines and recent data recommend spleen-preserving D2 lymph node resection for patients with resectable gastric cancer if operative morbidity from D2 lymphadenectomy can be minimized. Pathologic evaluation of a minimum of 16 lymph nodes is recommended to consider the pathologic nodal (N) staging as complete.9,17,18 Patient Positioning and Assessment for Metastatic Disease For all gastrectomies, patients are placed in a supine position with both arms extended, a urinary catheter is placed, and lower extremity compression devices Descargado para Anonymous User (n/a) en University of the Americas de ClinicalKey.es por Elsevier en diciembre 11, 2024. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2024. Elsevier Inc. Todos los derechos reservados. 6 Yu et al are placed for venous thromboembolism prophylaxis. The abdomen is prepped widely from the xyphoid to the pubis and draped in the usual fashion. Broad spectrum anti- biotics are recommended prior to incision. A nasogastric tube is placed for gastric decompression. A staging laparoscopy is performed to assess for radiographically occult metastatic disease. Once abdominal entry has been achieved, usually via a midline laparotomy incision, the patient is placed in reverse Trendelenburg position, and a liver retractor is placed to retract the left lateral section of the liver. A thorough inspection of the abdomen is conducted to assess for metastatic disease prior to sur- gical resection. Open Total Gastrectomy The operation begins with the division of the gastrocolic ligament off of the transverse colon, entering the lesser sac. Care must be taken to avoid injury to the transverse mesocolon. The posterior wall of the stomach is visualized to determine tumor inva- sion into adjacent structures, including the transverse colon and mesocolon, pancreas, and spleen. The dissection proceeds superolaterally toward the splenic flexure of the colon. The stomach is retracted toward the right, exposing the LGEA and short gastric vessels, which are ligated as the dissection proceeds until the left diaphragmatic crus. Division of the omentum off of the transverse colon is then continued medially toward the hepatic flexure of the colon until approximately 2 to 3 cm distal to the pylorus. The right gastroepiploic vein (RGEV) is identified, ligated, and divided at its insertion into the superior mesenteric vein. Next, the gastrohepatic ligament is divided close to the liver, and the dissection con- tinues toward the right crus of the diaphragm. A replaced or accessory left hepatic artery may course through the gastrohepatic ligament, so care must be taken to identify and control this vessel. The esophageal hiatus is dissected, dividing the phrenoesophageal ligament, and ensuring the abdominal portion of the esophagus is mobilized circumfer- entially. The left gastric artery is divided at its origin ensuring all lymphovascular tissue is mobilized toward the specimen. Dissection of the lymphovascular tissue is carried to- ward the intraabdominal esophagus, and the pericardial lymph nodes are removed with the specimen. The RGA is divided at its origin. The first portion of duodenum is cir- cumferentially dissected. The GDA should be identified and preserved during this portion of the dissection. The duodenum and distal esophagus are divided with a linear stapler, ensuring that an adequate proximal margin of 4 to 6 cm is obtained. Care must be taken to ensure that the nasogastric tube has been removed prior to firing the stapler. A frozen section of the distal esophagus can be sent to assess margin status. Additional lymphadenectomy along the proper and common hepatic artery and the medial splenic artery can be performed at this time if a D2 lymphadenectomy is performed. While D2 lymphadenectomy has not been demonstrated to improve overall survival, assessment of at least 16 lymph nodes is necessary for adequate staging. Two options for reconstruction are prevalent: reconstruction with a Roux-en-Y esophagojejunostomy or a Hunt-Lawrence jejunal pouch.22 Randomized controlled trials have demonstrated a decreased rate of long-term postoperative complications such as remnant gastritis, reflux esophagitis, and dumping symptoms following Roux- en-Y reconstruction, which is described later23 (Fig. 2). Approximately 30 to 50 cm from the ligament of Treitz, the jejunum is divided using a linear stapler to create the Roux limb distally and the biliopancreatic limb proximally. A jejunojejunostomy between the biliopancreatic and Roux limb is made 60 to 70 cm distal along the Roux limb. The mesenteric defect is closed to prevent an internal her- nia, and the end of the Roux limb is brought up to the esophagus in an antecolic fashion to create an esophagojejunostomy. This anastomosis can be performed in a Descargado para Anonymous User (n/a) en University of the Americas de ClinicalKey.es por Elsevier en diciembre 11, 2024. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2024. Elsevier Inc. Todos los derechos reservados.  Open Gastric Surgery for Gastric Cancer 7 Fig. 2. Total gastrectomy with Roux-en-Y esophagojejunostomy. (Printed with permission from ªMount Sinai Health System.) variety of ways: stapled end-to-end esophagojejunostomy with an EEA 25 stapler, sta- pled side-to-side esophagojejunostomy with handsewn closure of the common enter- otomy described by Orringer and colleagues,24 or handsewn end-to-end or end-to- side esophagojejunostomy. A leak test can be performed by insufflating the esoph- agus while keeping the anastomosis submerged under saline. An optional feeding jejunostomy tube can be placed, if prolonged nil per os (NPO) status is anticipated, or if the patient had poor oral intake prior to surgery. The potential space between the Roux limb and the transverse mesocolon should be closed to prevent internal her- niation. If the Roux limb is brought up in a retrocolic fashion, the esophagojejunostomy should be reduced inferior to the transverse mesocolon to prevent obstruction. Open Distal Gastrectomy A distal or subtotal gastrectomy has similar initial steps as a total gastrectomy begin- ning with a diagnostic laparoscopy to assess for metastatic disease followed by midline laparotomy incision and thorough exploration for metastatic disease and placement of fixed retractors. The tumor should be identified clearly prior to mobiliza- tion. This can be accomplished through preoperative endoluminal tattoo of the lesion or endoscopy in the operating room. The dissection begins by detaching the greater omentum from the transverse colon. This dissection continues superolaterally 4 to 6 cm proximal to the tumor. The short gastric vessels are divided, if needed. The dissection then continues inferiorly and medially toward the first portion of the duo- denum, dividing the RGEV at its insertion into the superior mesenteric vein. Attention is then turned to the lesser curvature of the stomach. The gastrohepatic ligament is divided toward the right crus. The RGA is divided at its origin. The LGA is dissected and ligated at its origin. All lymphovascular tissue along the left gastric artery is mobi- lized toward the specimen. Lymphovascular tissue along the lesser curvature of the Descargado para Anonymous User (n/a) en University of the Americas de ClinicalKey.es por Elsevier en diciembre 11, 2024. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2024. Elsevier Inc. Todos los derechos reservados. 8 Yu et al stomach, including station 1 lymph nodes, is mobilized toward the specimen. The du- odenum is divided using a linear stapler after ensuring the nasogastric tube has been removed. The proximal stomach is divided in a similar fashion greater than 4 cm prox- imal to the tumor to ensure adequate oncologic margins. Once transected, frozen sec- tions should be sent to confirm histologically negative margins. If a D2 lymphadenectomy performed, all lymphovascular tissue along the LGA, common and proper hepatic arteries, and the medial splenic artery are resected. Reconstruction options include the Billroth I gastroduodenostomy, Billroth II gastro- jejunostomy, or Roux-en-Y gastrojejunostomy. Roux-en-Y reconstruction is per- formed in a similar fashion as described earlier in the section on total gastrectomy; however, a gastrojejunostomy is created instead of an esophagojejunostomy (Fig. 3). The Billroth I gastroduodenostomy has largely fallen out of favor, as it is only applicable when the gastric remnant and the duodenal stump can be approxi- mated without tension. Billroth II gastrojejunostomy is described later20 (Fig. 4). A mobile loop of proximal jejunum approximately 50 cm from the ligament of Treitz is brought up to the gastric remnant in antecolic fashion. A hand-sewn or stapled gastro- jejunostomy can be performed. To reduce the incidence of afferent limb syndrome, a side-to-side jejunojejunostomy (Braun anastomosis) between the proximal and distal segments of the jejunum may be performed. Open Proximal Gastrectomy An alternative to total gastrectomy for proximal gastric lesions is proximal gastrectomy. While it may confer some nutritional benefits, there is a higher incidence of bile reflux and anastomotic stenosis.25 Recent randomized clinical trials comparing proximal gas- trectomy with double tract reconstruction (DTR) and total gastrectomy have shown that overall survival and recurrence to be similar between the 2 cohorts.26–28 The procedure is similar to a total gastrectomy, but dissection is only carried out at the superior portion of the stomach. The greater curvature of the stomach is mobilized Fig. 3. Distal gastrectomy with Roux-en-Y gastrojejunostomy. (Printed with permission from ªMount Sinai Health System.) Descargado para Anonymous User (n/a) en University of the Americas de ClinicalKey.es por Elsevier en diciembre 11, 2024. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2024. Elsevier Inc. Todos los derechos reservados.  Open Gastric Surgery for Gastric Cancer 9 Fig. 4. Distal gastrectomy with Billroth II gastrojejunostomy. (Printed with permission from ªMount Sinai Health System.) along the gastrocolic ligament, and the splenic flexure is mobilized. The gastrohepatic ligament is dissected along the liver edge, and the esophagus is mobilized. The gastric body is transected using a linear stapler 4 to 6 cm inferior to the lower border of the tumor, and the esophagus is transected. The simplest and most physiologic reconstruction is the esophagogastrostomy (EG). A stapled anastomosis using an EEA or linear stapler can be used, or the anastomosis can be hand-sewn. While this anastomosis facilitates future endoscopic surveillance of the gastric remnant, there is a high incidence of bile reflux.28,29 Alternatively, a jejunal interposition (JI) reconstruction can be created, where an 8 to 15 cm long pedicled loop of proximal jejunum is placed between the esophagus and gastric remnant. This reduces the incidence of bile reflux, but can also increase operative time and be a reser- voir for residual food.30 Lastly, a DTR has been reported to have superior nutritional out- comes, with similar recovery and survival to total gastrectomy.31 To perform this reconstruction, the jejunum is divided 15 cm distal to the ligament of Treitz, and the distal jejunal limb is used to create an esophagojejunostomy. A gastrojejunostomy is performed 15 cm caudal to the esophagojejunostomy. Lastly, a jejunojejunostomy is made 25 cm below the gastrojejunostomy to restore bowel continuity32 (Fig. 5). With respect to oncologic outcomes, few studies have reviewed any differences between the reconstruction options. The 5-year overall survival (OS) rate between the EG and JI reconstruction options are similar (94.2% vs 96.9%, respectively).33 POST-OPERATIVE MANAGEMENT Post-gastrectomy clinical management should include early ambulation, aggressive pulmonary toilet, venous thromboembolism chemical prophylaxis, and intravenous resuscitation to ensure euvolemia and adequate urine output. Early post-operative complications include post-operative bleeding, wound infection, pneumonia, deep venous thrombosis, urinary tract infections, and anastomotic leaks. Descargado para Anonymous User (n/a) en University of the Americas de ClinicalKey.es por Elsevier en diciembre 11, 2024. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2024. Elsevier Inc. Todos los derechos reservados. 10 Yu et al Fig. 5. Proximal gastrectomy with double tract reconstruction. (Printed with permission from ªMount Sinai Health System.) A nasogastric tube is an option that can be left to protect the anastomosis; however, this is not routinely recommended as patients without decompression have fewer pul- monary complications and shorter hospital length of stay.34 A water-soluble upper GI contrast study can be performed on post-operative day 3 to 5 to assess the integrity of the anastomosis prior to beginning oral intake, but utility of this study has been debated in a patient without clinical signs or symptoms of a compromised anasto- mosis. Upper GI contrast study has a high false negative rate, and either an upper endoscopy or CT imaging with oral contrast is preferred.35,36 If a feeding jejunostomy tube was placed, enteral feedings can be initiated as a dilute solution at a low rate, and then increased slowly to the target rate. Patients should receive nutritional counseling to navigate expected nutritional challenges, including supplementation of iron, vitamin B12, and fat-soluble vitamins. The patient can be discharged when all criteria are met, which include adequate pain control, tolerating a post-gastrectomy diet, and ambulating well. OUTCOMES As with all cancers, prognosis following surgical resection is highly dependent on pathologic staging, histologic subtype, status of the resection margins, and the pa- tient’s ability to tolerate additional systemic or local treatments, if indicated. The 5- year OSby pathologic stage is Stage I 90%; Stage II 68% to 80%; Stage IIIA 50%; Stage IIIB 40%; Stage IIIC 20%.37,38 CLINICS CARE POINTS  Open gastrectomy should be considered for bulky tumors, T4 tumors with direct invasion of surrounding structures, and tumors with extensive lymphadenopathy. Descargado para Anonymous User (n/a) en University of the Americas de ClinicalKey.es por Elsevier en diciembre 11, 2024. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2024. Elsevier Inc. Todos los derechos reservados.  Open Gastric Surgery for Gastric Cancer 11  The NCCN guidelines previously recommended 4 cm margins from the gross tumor, though it has been updated to negative microscopic margins.  For patients undergoing subtotal gastrectomy, the European Society of Medical Oncology recommends a 5 cm macroscopic proximal margin for intestinal type cancers and 8 cm in diffuse type cancers.  Oncologic outcomes are similar between total and subtotal gastrectomy when negative margins can be achieved.  Pathologic examination of at least 16 lymph nodes is needed for adequate nodal staging.  When performing an antecolic Roux-en-Y gastrojejunostomy, closure of the mesenteric defects, including the space between the transverse mesocolon and the Roux limb mesentery, is recommended to prevent internal hernia.  Careful dietetic surveillance and education is essential following total gastrectomy as these patients are at high risk of developing malnutrition and vitamin deficiencies. ACKNOWLEDGMENTS The authors would like to thank Lily Armstrong-Davies, Lead Academic Medical Illus- trator, Mount Sinai Health System. DISCLOSURES The authors of the article have no competing interests or disclosures to declare. REFERENCES 1. Sung H, Ferlay J, Siegel RL, et al. Global Cancer Statistics 2020: GLOBOCAN Es- timates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin 2021;71(3):209–49. 2. Plummer M, Franceschi S, Vignat J, et al. Global burden of gastric cancer attrib- utable to Helicobacter pylori. Int J Cancer 2015;136(2):487–90. 3. Ilic M, Ilic I. Epidemiology of stomach cancer. World J Gastroenterol 2022;28(12): 1187–203. 4. Cancer Genome Atlas Research N. Comprehensive molecular characterization of gastric adenocarcinoma. Nature 2014;513(7517):202–9. 5. 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