Gastrectomy

10 min read Last updated April 8, 2026

Surgical approach

  • Indications: gastric cancer (most common), bleeding/ulcer complications, bariatric (sleeve) differs; this note focuses on oncological partial/total gastrectomy
  • Approach: open upper midline laparotomy or laparoscopic/robotic (often converted if difficult)
    • Laparoscopic: pneumoperitoneum + reverse Trendelenburg; longer operating time; less pain; shoulder tip pain possible
    • Open: larger incision, more fluid shifts, higher pain burden
  • Subtotal (distal) gastrectomy: resection of distal stomach + lymphadenectomy; reconstruction typically Billroth II or Roux-en-Y gastrojejunostomy
  • Total gastrectomy: resection of entire stomach + D1/D2 lymphadenectomy; reconstruction oesophagojejunostomy (Roux-en-Y) ± feeding jejunostomy
    • Anastomosis high in upper abdomen/hiatus region; potential pleural breach; chest drain occasionally
  • Key intra-op steps relevant to anaesthesia: retraction of liver, dissection near pancreas/spleen, mobilisation near hiatus; potential major bleeding (left gastric, short gastrics, splenic injury)

Anaesthetic management

  • Type of anaesthesia: general anaesthesia with tracheal intubation; consider thoracic epidural or alternative regional techniques for open surgery
    • Regional options: thoracic epidural (T7–T9), or spinal opioid + TAP/rectus sheath blocks; for laparoscopic consider TAP/QL blocks + multimodal analgesia
  • Airway: ETT mandatory (aspiration risk, pneumoperitoneum, long duration, need for controlled ventilation). Consider rapid sequence induction if obstruction/delayed gastric emptying/bleeding
  • Duration: typically 3–6 hours (laparoscopic often longer early in learning curve; total gastrectomy often longer than subtotal)
  • Pain: moderate–severe (open upper abdominal incision); laparoscopic moderate. Aim opioid-sparing with neuraxial/regional + multimodal
  • Monitoring: invasive arterial line (major surgery, blood loss, vasoactive support), large-bore IV access; consider CVC if poor access/vasopressors/TPN plans; temperature, urine output; consider cardiac output monitoring in high-risk
  • Ventilation: lung-protective (6–8 ml/kg IBW), PEEP; manage pneumoperitoneum effects; consider recruitment manoeuvres; check ETT position after reverse Trendelenburg
  • Fluids/haemodynamics: goal-directed therapy; avoid both hypovolaemia (AKI/anastomotic hypoperfusion) and overload (pulmonary complications). Early vasopressor support often preferable to excess crystalloid
  • PONV prophylaxis: high risk; use multimodal (dexamethasone + ondansetron ± droperidol), minimise volatile/opioids where possible
  • Post-op destination: HDU/ICU for total gastrectomy, open surgery, high-risk patients, major blood loss, significant comorbidity, or epidural requiring close monitoring

Pre-operative assessment and optimisation

  • Assess indication and extent: subtotal vs total; open vs laparoscopic; planned feeding jejunostomy; expected blood loss; likelihood of conversion
  • Comorbidity and physiology: older patients, malnutrition, frailty, anaemia, cardiorespiratory disease; consider CPET if time and uncertainty about functional capacity
  • Aspiration risk: gastric outlet obstruction, bleeding, delayed gastric emptying, opioids; consider NG decompression pre-induction if obstructed (surgeon preference) and RSI
    • If NG present: leave on free drainage/suction before induction; be prepared for large volumes
  • Anaemia and transfusion planning: check Hb, iron studies; treat iron deficiency; group and screen/crossmatch (often 2–4 units depending on extent and local practice)
  • Nutrition: weight loss, hypoalbuminaemia; consider dietitian input, prehabilitation, carbohydrate loading if appropriate; discuss post-op feeding plan (jejunal feeds/TPN)
  • Medication review: anticoagulants/antiplatelets (balance bleeding vs thrombosis), steroids (stress dose if indicated), beta-blockers, ACEi/ARB plan
  • Consent discussion (anaesthetic): epidural risks/benefits, arterial line, blood transfusion, ICU, post-op ventilation possibility (rare but consider in high-risk)

Intra-operative conduct (key FRCA points)

  • Induction: consider RSI if obstruction/bleeding/high aspiration risk; otherwise modified RSI may be appropriate. Ensure robust IV access before induction if possible
    • Haemodynamic stability: induction can unmask hypovolaemia from poor intake; consider gentle induction and early vasopressor (metaraminol/noradrenaline)
  • Analgesia: thoracic epidural (local anaesthetic + opioid) for open surgery reduces opioid requirements and improves respiratory mechanics; ensure haemodynamic plan for sympathectomy
    • Alternatives: TAP/QL blocks, rectus sheath (midline), wound catheters, IV lidocaine infusion (where used), ketamine low-dose, paracetamol; NSAIDs cautiously (bleeding/renal risk; surgeon preference re anastomosis)
  • Monitoring: A-line before incision; active warming (forced-air + warmed fluids); urinary catheter; consider serial ABG/lactate if major blood loss or high-risk
  • Fluid and blood: balanced crystalloid; consider albumin/blood products if significant loss; use cell salvage if appropriate (often acceptable in cancer surgery with modern leukocyte depletion filters per local policy)
    • Coagulation: consider fibrinogen early in major haemorrhage; use viscoelastic testing if available
  • Ventilation and pneumoperitoneum (laparoscopic): increased airway pressures, reduced compliance; manage with PEEP, recruitment, adjust I:E; monitor EtCO2 rise; consider pressure-controlled ventilation
  • Positioning: reverse Trendelenburg (laparoscopic) increases V/Q mismatch and hypotension risk; secure patient; protect pressure points; consider DVT prophylaxis (mechanical intra-op)
  • Antibiotics: broad-spectrum as per local upper GI protocol; redose if prolonged surgery or major blood loss
  • Antiemetics: multimodal; consider TIVA to reduce PONV in high-risk
  • Extubation: ensure normothermia, adequate analgesia, acceptable gas exchange; consider ICU ventilation if ongoing bleeding, acidosis, hypothermia, high vasopressor requirement, or severe comorbidity

Post-operative management

  • Analgesia: epidural infusion with regular assessment (sensory level, motor block, hypotension); or PCA opioid + regional blocks + paracetamol ± ketamine/lidocaine (local policy)
  • Respiratory care: early mobilisation, physiotherapy, incentive spirometry; treat pain to enable deep breathing/cough; consider CPAP in OSA or atelectasis
  • Fluids and electrolytes: avoid overload; monitor UO, lactate, creatinine; manage epidural-related hypotension with vasopressors rather than excess fluid where appropriate
  • Nutrition: early enteral feeding often via jejunostomy; NG tube may be left for decompression depending on surgeon; coordinate with ERAS
  • Glycaemic control: avoid hyperglycaemia (infection risk) and hypoglycaemia (limited oral intake)
  • Thromboprophylaxis: mechanical + pharmacological when safe; cancer surgery often requires extended prophylaxis (local policy)
  • Complications to anticipate: bleeding, anastomotic leak, pancreatic injury/fistula, ileus, aspiration/pneumonia, AKI, arrhythmias, sepsis

Procedure-specific physiology and complications (useful for viva)

  • Anastomotic leak (oesophagojejunostomy/gastrojejunostomy): typically day 3–7; presents with tachycardia, fever, pain, rising inflammatory markers, sepsis, respiratory compromise
    • Anaesthetic implications: high suspicion in unexplained tachycardia; early imaging (CT with contrast), source control; may require return to theatre/ICU
  • Bleeding: intra-op from major vessels/spleen; post-op intraluminal or intra-abdominal bleeding
  • Respiratory complications: atelectasis, pneumonia (upper abdominal surgery), pleural effusion; higher risk with open surgery, poor analgesia, smoking, COPD
  • Metabolic/nutritional sequelae (later): dumping syndrome, B12 deficiency (total gastrectomy), iron deficiency, weight loss; relevant to long-term but may affect pre-op status in revision surgery
You are asked to anaesthetise a 72-year-old for an open total gastrectomy. What are your key pre-operative concerns and how will you optimise them?

Structure: patient factors, disease factors, operation factors, optimisation and planning.

  • Patient factors: frailty, functional capacity, cardiopulmonary disease (IHD/CCF/COPD), renal function, diabetes, OSA; assess exercise tolerance ± CPET; ECG ± echo if indicated
  • Disease factors: weight loss/malnutrition, anaemia, hypoalbuminaemia, electrolyte disturbance; aspiration risk (obstruction/bleeding); sepsis if perforation/bleeding complications
  • Optimisation: treat anaemia (IV iron ± transfusion if urgent), nutrition/prehabilitation, smoking cessation, bronchodilator optimisation, plan peri-op steroids if chronic use
  • Planning: HDU/ICU bed, blood availability (crossmatch), analgesia plan (epidural vs alternatives), aspiration strategy (NG decompression/RSI), thromboprophylaxis and anticoagulant management
How would you decide between a thoracic epidural and alternative analgesic techniques for gastrectomy?

Compare efficacy, risks, and suitability to surgical approach and patient factors.

  • Epidural benefits (open): excellent dynamic analgesia, reduced systemic opioids, improved cough/physio, potentially fewer pulmonary complications; facilitates early mobilisation
  • Epidural downsides: hypotension (sympathectomy), urinary retention, failure rate, motor block, rare neuraxial complications; contraindications (coagulopathy/anticoagulants, sepsis, patient refusal)
  • Alternatives: TAP/QL blocks + PCA; rectus sheath for midline incision; wound catheters; intrathecal opioid; IV lidocaine/ketamine; multimodal non-opioids
  • Laparoscopic: often adequate with blocks + multimodal; epidural may be reserved for conversion risk, chronic pain/opioid tolerance, or high pain expectation
Describe your induction and airway plan for a patient with gastric outlet obstruction undergoing gastrectomy.

Aim: minimise aspiration risk and maintain haemodynamic stability.

  • Preparation: senior help, suction ready, head-up preoxygenation, consider NG tube decompression on suction (if present/placed), aspiration prophylaxis as per local policy (e.g., H2 blocker/PPI, sodium citrate if appropriate)
  • Induction: RSI with cricoid pressure (applied correctly, released if impedes intubation/ventilation); avoid mask ventilation if possible; use appropriate induction agent dose (often reduced if hypovolaemic)
  • Intubation: cuffed ETT, confirm with capnography; consider video laryngoscopy early if predicted difficulty; secure tube (long case, position changes)
  • If aspiration occurs: suction, 100% O2, consider bronchoscopy if particulate, PEEP, treat bronchospasm, antibiotics not routine unless infection suspected; document and plan post-op care
What monitoring and vascular access would you use for an open total gastrectomy, and why?

Justify each item based on risk: bleeding, haemodynamic instability, prolonged surgery, and need for vasoactive drugs.

  • Standard monitoring + temperature + neuromuscular monitoring (long case, ensure full reversal)
  • Arterial line: beat-to-beat BP, frequent ABG (Hb, lactate, electrolytes), blood sampling during haemorrhage
  • IV access: at least 2 wide-bore cannulae; consider rapid infuser availability; blood warmer
  • CVC: if poor peripheral access, anticipated vasopressors, major fluid shifts, or need for postoperative TPN; not mandatory for all
  • Cardiac output monitoring: consider in high-risk patients to guide GDFT and vasopressor/inotrope use
How will you manage fluids and haemodynamics intra-operatively? Include how an epidural changes your approach.

Balance organ perfusion and anastomotic perfusion against overload; treat vasodilation appropriately.

  • Use goal-directed therapy where available (stroke volume optimisation) with balanced crystalloid; avoid large positive balance
  • Epidural-related hypotension: treat with vasopressors (metaraminol/noradrenaline) and judicious fluid; avoid reflex over-resuscitation
  • Blood loss: early recognition; activate major haemorrhage protocol if needed; use RBC + plasma + platelets guided by labs/viscoelastic testing; correct hypocalcaemia and hypothermia
  • Urine output and lactate: interpret in context (epidural/vasopressors); aim for adequate perfusion rather than fixed UO targets alone
What are the main respiratory issues during laparoscopic gastrectomy and how do you manage them?

Pneumoperitoneum + reverse Trendelenburg drive changes in compliance, V/Q, and CO2.

  • Effects: reduced compliance, increased airway pressures, atelectasis; increased PaCO2/EtCO2; reverse Trendelenburg may worsen V/Q mismatch and reduce venous return
  • Management: lung-protective ventilation, adequate PEEP, recruitment manoeuvres, adjust minute ventilation for CO2, consider pressure control; ensure adequate depth and paralysis to facilitate lower insufflation pressures
  • Haemodynamics: treat hypotension with vasopressors and optimisation of preload; communicate with surgeon about insufflation pressure and position
A patient becomes hypotensive and tachycardic during lymph node dissection. What are your differential diagnoses and immediate management?

Use an A–E approach and consider surgical causes early.

  • Differentials: haemorrhage (major vessel/splenic injury), anaesthetic depth/vasodilation (epidural/volatile), pneumoperitoneum effects, arrhythmia/MI, anaphylaxis, tension pneumothorax (rare; pleural breach), sepsis (less likely intra-op)
  • Immediate actions: call for help; increase FiO2; check pulse/rhythm, capnography, airway pressures; rapid assessment of surgical field and suction canister; ask surgeon to pause and assess bleeding; reduce insufflation if laparoscopic
  • Resuscitation: vasopressors (metaraminol/phenylephrine; start noradrenaline if ongoing), fluid bolus if responsive, activate MHP if bleeding suspected, send urgent ABG/Hb/coag, warm patient, give calcium if massive transfusion
Outline your postoperative plan for a high-risk patient after total gastrectomy.

Cover destination, analgesia, respiratory care, fluids, nutrition, and complication surveillance.

  • Destination: HDU/ICU for close haemodynamic monitoring, epidural management, and early detection of complications
  • Analgesia: continue epidural with protocolised observations; or PCA + regional blocks; regular paracetamol; consider ketamine/lidocaine per policy; avoid excessive sedation
  • Respiratory: oxygen, physiotherapy, early mobilisation, treat atelectasis; consider CPAP if needed; monitor for aspiration/pneumonia
  • Haemodynamics/fluids: maintain perfusion, avoid overload; vasopressors rather than large fluids if vasodilated; monitor lactate, UO, creatinine, electrolytes
  • Nutrition: coordinate jejunal feeding/TPN plan; glycaemic control; antiemetics; NG management per surgeon
  • Surveillance: bleeding, anastomotic leak (tachycardia/fever/sepsis), pancreatic fistula, ileus; early escalation and imaging if concern
What are the causes of tachycardia on day 4 after gastrectomy, and how would you investigate and manage it?

Day 3–7 tachycardia is a key warning sign for anastomotic leak/sepsis until proven otherwise.

  • Causes: anastomotic leak/sepsis, bleeding/anaemia, pain, hypovolaemia, PE, pneumonia/atelectasis, AF, MI, drug withdrawal
  • Assessment: A–E, full obs, fluid balance, examine chest/abdomen/wounds/drains; ECG; ABG/lactate; FBC/U&E/CRP; cultures if febrile
  • Investigations: CXR; CT chest/abdomen/pelvis with contrast if leak/collection suspected; consider CTPA if PE suspected
  • Management: treat sepsis early (antibiotics, fluids/vasopressors, source control); oxygen/resp support; treat pain; transfuse if significant anaemia; anticoagulate if PE confirmed (balance bleeding risk)
Discuss blood conservation strategies for gastrectomy.

Think pre-op, intra-op, and post-op.

  • Pre-op: identify and treat anaemia (IV iron), optimise coagulation, manage anticoagulants/antiplatelets, consider tranexamic acid where appropriate (local policy and bleeding risk)
  • Intra-op: meticulous temperature control, permissive hypotension generally not appropriate (anastomosis perfusion); cell salvage if policy allows; minimise haemodilution; use viscoelastic-guided product replacement
  • Post-op: restrictive transfusion thresholds tailored to symptoms/comorbidity; treat ongoing losses; early detection of bleeding

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