The arterial blood supply to the stomach is rich and comes from multiple sources. These include the left gastric artery (branch of the celiac axis), right gastric artery (branch of the hepatic artery), and right and left gastroepiploic arteries, which form an arcade along the greater curvature and short gastric arteries from the superior pole of the spleen that supply the cardia. In general, maintenance of the short gastric arteries is enough to provide adequate arterial blood supply to the gastric remnant during subtotal gastrectomy.

Lymph node basins in which gastric cancer can commonly spread can be divided into various regions based upon their proximity to the primary tumor. Perigastric lymph nodes and those near the left gastric artery and celiac axis are considered first-echelon nodal basins. Lymph nodes along the common hepatic artery, porta hepatis, aorta, and peripancreatic and perisplenic left renal hilum are considered second-echelon nodal basins and can be resected with increased morbidity and debatable improvements in overall survival.

Cancers of the stomach can be in proximity or directly invade the distal esophagus, diaphragmatic hiatus or crura, pericardium, spleen, celiac axis, pancreas, adrenal gland, and left kidney. They can also frequently metastasize to the omentum, peritoneum, and liver. Gastric cancers that are best treated by subtotal gastrectomy are those that involve the antrum or fundus; tumors of the proximal stomach and cardia are best served by total gastrectomy or esophagogastrectomy.

It is critically important to properly stage any patient who is being considered for subtotal gastrectomy for cancer prior to any operative intervention. Patients with locally advanced tumors that are directly invading surrounding structures such as the main celiac trunk, diaphragmatic hiatus, or pericardium, as well as those patients who present with metastases to liver or lung may be best served with some combination of systemic therapy and radiation, depending upon whether they have symptoms of bleeding or obstruction. In general these advanced tumors have a low chance of cure and any surgical attempts are oriented towards palliation.

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  Upper endoscopy and endoscopic ultrasound can be useful in determining the location and extent of disease spread within the gastric wall, as well as providing a method of diagnosis via endoscopic biopsy.

  
  
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  Submucosal tumors should be sent for CD117 immunostaining to determine whether a gastrointestinal stromal tumor is present. These tumors, if small and localized, can sometimes be resected via wedge resection, and subtotal gastrectomy can be avoided.

  
  
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  Biopsies of mucosal tumors that demonstrate a diffuse, infiltrative signet ring cell histology may be best served with total gastrectomy, particularly if the mucosal ulcerations extend over a broad surface towards the proximal stomach.

  
  
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  Anesthesia considerations are similar to any major abdominal surgical procedure. The anesthesia team should be aware of the need for possible insertion and manipulation of a nasogastric tube, as well as the possibility of intraoperative endoscopy.

  
  
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  Patient instructions and consent are also important for success. Patients should be aware of prolonged hospitalization, which could be related to possible complications from anastomotic leaks or intraabdominal abscesses. The patient will likely lose up to 10% to 20% of their body weight and may not regain it after the surgery. They may also require prolonged enteral nutritional supplements via jejunostomy feedings, and they should be made aware of this possibility.

In general, it is reasonable to perform intraoperative upper endoscopy and diagnostic laparoscopy to help plan surgical resection. Those patients with unsuspected metastatic disease to the peritoneum or liver may be best served with feeding jejunostomy if the patient has limited symptoms. The use of self-retaining retractor systems will facilitate exposure and ease of operation.