A 58-year-old man from rural India presents with progressive dysphagia to solids for 4 months, early satiety, and a 6 kg weight loss. Upper endoscopy reveals a 4 cm ulcerated lesion in the gastric antrum with surrounding erythema. Biopsy confirms adenocarcinoma. CT staging shows no distant metastases, but there is thickening of the gastric wall extending into the muscularis propria with involvement of 3 regional lymph nodes. The patient is fit for surgery. What is the most appropriate surgical management?

Explanation

## Clinical Assessment **Key Point:** This patient has T2N1M0 gastric cancer (stage IB–II) localized to the distal antrum with resectable regional lymph node involvement and no distant metastases. ## Surgical Decision-Making ### Extent of Gastrectomy - **Distal (antral) tumors:** Distal gastrectomy is adequate if the proximal margin is ≥5 cm from the tumor. - **Total gastrectomy:** Reserved for proximal/cardia tumors, diffuse tumors (linitis plastica), or when adequate proximal margin cannot be achieved. - In this case, the 4 cm antral lesion allows safe distal resection with adequate margins. ### Lymphadenectomy Standard - **D2 lymphadenectomy** is the standard of care for curative-intent gastric cancer surgery in fit patients [cite:Japanese Gastric Cancer Association Guidelines]. - D2 includes removal of perigastric nodes (D1) plus nodes along the left gastric, celiac, splenic, and hepatic arteries. - Improves long-term survival in T2–T4 tumors with nodal involvement. ### Reconstruction Method - **Billroth II (gastrojejunostomy)** is preferred for distal gastrectomy: - Lower incidence of afferent loop syndrome compared to Billroth I. - Better long-term nutritional outcomes. - Standard reconstruction in Japanese and European guidelines. - Billroth I (gastroduodenostomy) is an alternative if the duodenum is mobile and tension-free. **Clinical Pearl:** Roux-en-Y is reserved for total gastrectomy (to prevent reflux esophagitis) or when Billroth II is not feasible. ## Why Distal Gastrectomy Here 1. **Tumor location:** Antral (distal) → distal gastrectomy sufficient. 2. **Resectability:** No involvement of proximal stomach or cardia. 3. **Lymph node status:** N1 (3 nodes) → D2 lymphadenectomy indicated. 4. **Fitness:** Patient is a surgical candidate without contraindications. **High-Yield:** The combination of distal location + T2N1M0 stage + fit patient = **distal gastrectomy + D2 + Billroth II** is the gold standard.