A 58-year-old man from rural Maharashtra presents with epigastric pain and early satiety. Endoscopy reveals a 6 cm ulcerated mass in the proximal stomach. CT staging shows no distant metastases, but perigastric and celiac axis lymph nodes are enlarged. Regarding his surgical management, all of the following are appropriate EXCEPT:

Explanation

## Surgical Strategy for Proximal Gastric Cancer with Lymph Node Involvement ### Case Context **Clinical Pearl:** This patient has a proximal gastric cancer (upper third) with regional lymph node involvement (N1–N2 disease). Curative surgery requires total gastrectomy with D2 lymphadenectomy. ### Appropriate Surgical Decisions #### Total Gastrectomy + D2 Lymphadenectomy **Key Point:** Proximal gastric cancers MUST be treated with total gastrectomy because: - Proximal location requires adequate margins (≥5 cm) that cannot be achieved with subtotal resection - Distal stomach cannot be preserved without compromising margin adequacy - D2 lymphadenectomy is standard for fit patients with resectable disease #### Distal Pancreatectomy (When Indicated) **High-Yield:** Distal pancreatectomy is appropriate if: - Tumor directly invades the pancreatic body or tail - Involved pancreatic lymph nodes require en bloc resection - Patient has adequate performance status This is part of aggressive R0 resection strategy and is justified in fit patients. #### Reconstruction After Total Gastrectomy **Key Point:** After total gastrectomy, reconstruction options include: - Billroth II (gastrojejunostomy): Simple, commonly used - Roux-en-Y (esophagojejunostomy): Preferred by many surgeons to reduce bile reflux - Hunt-Lawrence pouch: Rarely used Both Billroth II and Roux-en-Y are acceptable; choice depends on surgeon preference and patient factors. ### Why Routine Splenectomy Is WRONG **Warning:** Splenectomy should NOT be routinely performed in proximal gastric cancer. It is selective, indicated only when: - Tumor directly invades the spleen - Splenic vessels are involved - Splenic hilar lymph nodes are involved **Clinical Pearl:** Routine splenectomy in proximal gastric cancer: - Increases operative time and blood loss - Increases risk of post-splenectomy sepsis (OPSI — overwhelming post-splenectomy infection) - Does NOT improve survival when spleen is not involved - Is NOT part of standard D2 lymphadenectomy ### Decision Algorithm ```mermaid flowchart TD A[Proximal gastric cancer]:::outcome --> B{Direct splenic invasion?}:::decision B -->|Yes| C[En bloc splenectomy]:::action B -->|No| D{Splenic vessel involvement?}:::decision D -->|Yes| E[Splenectomy for vascular control]:::action D -->|No| F{Splenic hilar nodes involved?}:::decision F -->|Yes| G[Splenectomy for lymphadenectomy]:::action F -->|No| H[Preserve spleen]:::action C --> I[Total gastrectomy + D2 lymphadenectomy]:::action E --> I G --> I H --> I ``` **High-Yield:** The statement "Splenectomy should be performed as part of routine en bloc resection for proximal gastric cancer" is FALSE. Splenectomy is selective, not routine.