Linitis plastica surgery

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Hadeel Maksoud M.D.[2]

Total gastrectomy is recommended for the management of local disease. However, it is important to note that patients with linitis plastica usually present at an advanced stage when metastasis has already occurred, surgery at this point is often not curative but rather improves the chances of survival. Surgical resection is not recommended among patients with metastatic linitis plastica, radiotherapy and chemotherapy are utilized instead.

• The surgery of choice in linitis plastica is a total gastrectomy.^[1][2]
• A total gastrectomy is total resection of the stomach including the cardia and pylorus.

• Pancreaticosplenectomy
  • Pancreatic invasion by tumor requires total gastrectomy regardless of the tumor location.
• Total gastrectomy with splenectomy
  • It should be considered for tumors that are located along the greater curvature with metastasis to 4 or more lymph nodes.

• One of the most controversial areas in the surgical management of gastric cancer is the optimal extent of lymph node dissection.^[3]
• The draining lymph nodes for the stomach have been meticulously divided into 16 stations by Japanese surgeons; stations 1 to 6 are perigastric, and the remaining 10 are located adjacent to major vessels, behind the pancreas, and along the aorta.^[4]

D1 lymphadenectomy

• It refers to a dissection of only the perigastric lymph nodes.
• A D1 lymphadenectomy is indicated for T1a tumors that do not meet the criteria for EMR/ ESD and for T1bN0 tumors that are histologically of differentiated type and 1.5 cm or smaller in diameter.

D2 lymphadenectomy

• It is an extended lymph node dissection, includes removal of nodes along the hepatic, left gastric, celiac, and splenic arteries, as well as those in the splenic hilum.
• It is indicated for potentially curable T2-T4 tumors.
• A D2 lymphadenectomy should be performed whenever nodal involvement is suspected.

D3 dissection

• It is a superextended lymphadenectomy. The surgery includes D2 lymphadenectomy plus the removal of nodes within the porta hepatis and periaortic regions.^[5]

• Palliative resection
  • Palliative gastrectomy should be reserved for extreme, highly symptomatic cases where less invasive methods cannot be used.^[6]
  • Two-year survival for chemotherapy alone versus gastrectomy plus chemotherapy was 32 versus 25 percent.
  • Patients undergoing gastrectomy had a significantly higher incidence of several serious adverse events related to chemotherapy, including leucopenia, nausea, anorexia, and hyponatremia.

Total gastrectomy

• Roux-en-Y esophagojejunostomy^[7]
• Jejunal interposition
• Double tract method

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