A 58-year-old Indian man presents with a 4-month history of progressive dysphagia to solids, early satiety, and a 6 kg weight loss. He denies vomiting or haematemesis. On examination, he is cachectic with a palpable epigastric mass. Upper endoscopy reveals a 5 cm ulcerated lesion in the gastric antrum with rolled edges; biopsies confirm adenocarcinoma. CT staging shows no distant metastases, but there is thickening of the gastric wall with involvement of perigastric lymph nodes (N2). The tumour does not involve the pylorus or extend into the duodenum. What is the most appropriate surgical management?

Explanation

## Surgical Strategy for Antral Gastric Cancer **Key Point:** Antral tumours in the distal stomach without pyloric involvement or duodenal extension are best managed by subtotal (distal) gastrectomy, not total gastrectomy. ### Rationale for Subtotal Gastrectomy 1. **Tumour location:** The lesion is in the antrum (distal stomach), which permits preservation of the proximal stomach and cardia. 2. **Margin adequacy:** A 5 cm proximal margin of normal tissue is achievable in antral cancers with subtotal resection. 3. **Lymph node involvement:** N2 disease (perigastric nodes) is still resectable with curative intent; D2 lymphadenectomy is the standard for potentially curable gastric cancer in India and Asia [cite:Datta Textbook of Surgery 7e]. 4. **Reconstruction:** Billroth II (gastrojejunostomy) is the standard reconstruction after subtotal gastrectomy, avoiding the bile reflux and dumping issues of Billroth I. 5. **Functional preservation:** Subtotal gastrectomy preserves the proximal stomach, maintaining better postoperative quality of life and nutritional tolerance compared to total gastrectomy. ### When Total Gastrectomy Is Indicated - Tumour in the cardia or proximal stomach - Diffuse-type (linitis plastica) gastric cancer - Tumour within 5 cm of the gastro-oesophageal junction - Involvement of the proximal stomach by tumour or direct extension **High-Yield:** In antral gastric cancer without proximal involvement, subtotal gastrectomy + D2 lymphadenectomy is the gold standard curative approach. **Clinical Pearl:** The 5 cm proximal margin rule ensures adequate oncological clearance while preserving functional stomach in distal tumours. ### Why Other Options Fail | Option | Why Incorrect | |--------|---------------| | Total gastrectomy | Unnecessary for antral tumours; removes proximal stomach without oncological benefit; increases morbidity (nutritional, dumping, bile reflux). | | Palliative bypass | Patient has resectable disease (no distant metastases, N2 nodes); curative surgery is the goal, not palliation. | | Endoscopic mucosal resection | Appropriate only for early gastric cancer (T1a, <2 cm); this is a 5 cm advanced ulcerated lesion with transmural involvement. |