Regarding the surgical management of gastric cancer, all of the following statements are TRUE EXCEPT:

Explanation

## Analysis of Surgical Principles in Gastric Cancer ### Correct Statements (Options 0, 1, 3) **Key Point:** D2 lymphadenectomy (removal of lymph nodes in the second tier around the primary tumor) is the standard curative-intent approach for resectable gastric cancer and is recommended by major international guidelines including JGCA and NCCN. **Key Point:** Total gastrectomy is indeed the preferred approach for proximal gastric cancers (cardia, fundus) to achieve adequate proximal margins (typically ≥5 cm) and to avoid anastomosis in contaminated fields. **Key Point:** Splenectomy is often necessary during distal gastrectomy when the left gastric vessels or splenic vessels are involved by tumor or when the spleen is directly invaded, as these are part of the en bloc resection principle. ### The FALSE Statement (Option 2) **High-Yield:** Billroth I (gastroduodenostomy) reconstruction is NOT contraindicated after gastrectomy for gastric cancer. In fact, Billroth I is the preferred reconstruction method after distal gastrectomy when the duodenum is healthy and can be mobilized without tension. It maintains physiologic anatomy and has lower rates of dumping syndrome and bile reflux compared to Billroth II. **Clinical Pearl:** The choice between Billroth I and Billroth II depends on: - Duodenal involvement (if involved → Billroth II) - Tension on anastomosis (if high tension → Billroth II) - Surgeon preference and local factors Billroth I is actually preferred when feasible because it avoids the blind loop syndrome and has better long-term functional outcomes. ### Reconstruction Options After Gastrectomy | Reconstruction Type | Indications | Advantages | Disadvantages | |---|---|---|---| | Billroth I | Distal gastrectomy, healthy duodenum, no tension | Physiologic, lower dumping | Requires good duodenal mobilization | | Billroth II | Duodenal involvement, high tension, proximal cancer | Easier technically | Blind loop, bile reflux, dumping | | Roux-en-Y | Proximal gastrectomy, total gastrectomy | Prevents bile reflux | More complex, longer operative time | **Mnemonic:** **DRAB** for Billroth II indications — **D**uodenal involvement, **R**educed duodenal mobility, **A**natomic constraints, **B**iliary reflux prevention desired.