Stomach

Introduction to the Stomach

According to Love and Bailey’s “A Short Practice of Surgery”, the stomach is a J-shaped dilated portion of the gastrointestinal tract that serves as a reservoir for food and initiates the digestive process through mechanical and chemical means.

Clinical Significance

Primary organ for food storage and initial digestion
Site of common surgical conditions like PUD and gastric cancer
Gastric cancer is the 5th most common cancer worldwide
Peptic ulcer disease affects 4-10% of population
Major site for bariatric surgical procedures

Surgical Anatomy of the Stomach

Gross Anatomy and Relations

Part	Location	Relations
Cardia	T11 level, left of midline	Left lobe of liver anteriorly, diaphragm posteriorly
Fundus	Superior to cardia, dome-shaped	Left dome of diaphragm, spleen laterally
Body	Between fundus and antrum	Anterior: Left lobe liver, Posterior: Pancreas, spleen
Antrum	Distal third, prepyloric region	Gallbladder anteriorly, pancreas posteriorly
Pylorus	Gastroduodenal junction	First part of duodenum, portal vein posteriorly

Peritoneal Attachments

Ligament	Attachment	Contents	Clinical Significance
Gastrohepatic	Lesser curvature to liver	Left gastric artery, coronary vein, lymph nodes	Access to lesser sac, contains aberrant left hepatic artery
Gastrosplenic	Greater curvature to spleen	Short gastric vessels, left gastroepiploic vessels	Risk of splenic injury during gastrectomy
Gastrocolic	Greater curvature to transverse colon	Right and left gastroepiploic vessels	Access to lesser sac, important in gastric mobilization
Gastrophrenic	Fundus to diaphragm	Peritoneum only	Mobilization for fundoplication

Blood Supply

Artery	Origin	Distribution	Surgical Importance
Left Gastric	Celiac trunk	Lesser curvature, cardia, lower esophagus	First vessel ligated in gastrectomy, supplies anastomosis
Right Gastric	Common hepatic artery	Distal lesser curvature, pylorus	Preserved in pylorus-preserving procedures
Right Gastroepiploic	Gastroduodenal artery	Greater curvature, body, antrum	Major blood supply for gastric conduit
Left Gastroepiploic	Splenic artery	Upper greater curvature, fundus	Ligated during splenectomy, gastrectomy
Short Gastric	Splenic artery	Fundus of stomach	Ligated during fundoplication, splenectomy
Posterior Gastric	Splenic artery	Posterior wall of fundus	Present in 60% of individuals

Venous Drainage

Right and Left Gastric veins: Portal vein
Right Gastroepiploic vein: Superior mesenteric vein
Left Gastroepiploic and Short Gastric veins: Splenic vein
Clinical significance: Portal hypertension → gastric varices

Lymphatic Drainage

Zone	Primary Drainage	Secondary Drainage	Clinical Significance
Lower esophagus/cardia	Paracardial nodes	Left gastric, celiac nodes	Early spread of proximal gastric cancer
Lesser curvature	Left and right gastric nodes	Celiac nodes	Standard D2 lymphadenectomy includes these
Greater curvature (right)	Right gastroepiploic nodes	Subpyloric, hepatic nodes	Important in antral cancers
Greater curvature (left)	Left gastroepiploic nodes	Pancreaticosplenic nodes	Involved in fundic cancers
Pylorus	Supra- and subpyloric nodes	Hepatic, celiac nodes	Early nodal spread in distal cancers

Nerve Supply

Nerve	Origin	Function	Clinical Significance
Anterior Vagal Trunk	Left vagus nerve	Motor to stomach, pyloric relaxation, hepatic branch	Truncal vagotomy for PUD, highly selective preserves branches
Posterior Vagal Trunk	Right vagus nerve	Motor to stomach, celiac branch to intestine	Truncal vagotomy, must preserve celiac branch
Sympathetic Nerves	T6-T9 via greater splanchnic nerve	Vasomotor, inhibitory to motility, pain sensation	Pain referral to epigastrium

Histology of Gastric Wall

Layer	Composition	Function
Mucosa	Surface epithelium, lamina propria, muscularis mucosae	Secretion, absorption, barrier function
Submucosa	Loose connective tissue, vessels, nerves (Meissner’s plexus)	Nutrition, neural regulation
Muscularis Propria	Inner oblique, middle circular, outer longitudinal layers	Mixing and propulsion of gastric contents
Serosa	Visceral peritoneum	Reduces friction, contains blood vessels

Gastric Physiology

Gastric Secretions

Cell Type	Location	Secretion	Function
Parietal (Oxyntic) Cells	Body and fundus	Hydrochloric acid, intrinsic factor	Acidification, protein denaturation, B12 absorption
Chief (Zymogenic) Cells	Body and fundus	Pepsinogen, gastric lipase	Protein and fat digestion
Mucous Cells	Throughout stomach	Mucus, bicarbonate	Protection against acid and pepsin
G Cells	Antrum	Gastrin	Stimulates acid secretion, mucosal growth
D Cells	Antrum and body	Somatostatin	Inhibits acid secretion
Enterochromaffin-like (ECL) Cells	Body and fundus	Histamine	Stimulates acid secretion

Phases of Gastric Secretion

Phase	Stimulus	Mechanism	% of Total Secretion
Cephalic	Sight, smell, taste of food	Vagal stimulation via hypothalamus	30%
Gastric	Gastric distension, peptides	Local reflexes, gastrin release	60%
Intestinal	Chyme in duodenum	Enterogastrone release (secretin, CCK)	10%

Gastric Motility

Receptive relaxation: Fundic relaxation to accommodate food
Mixing waves: Peristaltic contractions in body (3/minute)
Gastric emptying: Regulated by pylorus, duodenal receptors
Factors delaying emptying: Fat, acid, hypertonicity, distension
Normal emptying time: 2-4 hours for mixed meal

Congenital Gastric Disorders

Pyloric Stenosis

Aspect	Details
Incidence	2-4 per 1000 live births, male:female = 4:1
Pathology	Hypertrophy and hyperplasia of pyloric circular muscle
Clinical Features	Non-bilious projectile vomiting at 3-6 weeks, visible peristalsis, palpable olive-shaped mass
Diagnosis	Clinical examination, ultrasound (muscle thickness >4mm, length >16mm)
Treatment	Ramstedt’s pyloromyotomy (longitudinal division of muscle)

Other Congenital Anomalies

Anomaly	Features	Treatment
Gastric Atresia	Rare, usually prepyloric, associated with polyhydramnios	Resection with gastroduodenostomy
Microgastria	Small tubular stomach, associated with malrotation	Gastric augmentation or feeding procedures
Gastric Duplication Cysts	Usually along greater curvature, may contain gastric mucosa	Excision if symptomatic
Congenital Gastric Volvulus	Organoaxial or mesenteroaxial rotation	Emergency derotation and fixation

Inflammatory Gastric Disorders

Peptic Ulcer Disease

Feature	Gastric Ulcer	Duodenal Ulcer
Location	Lesser curvature, antrum-body junction	First part of duodenum (95%)
Age	Older adults (40-70 years)	Younger adults (20-50 years)
Pain Pattern	Soon after eating, may be worsened by food	2-3 hours after meals, relieved by food
Acid Secretion	Normal or low	High
H. pylori Association	70-80%	90-95%
Malignancy Risk	2-4%	Virtually nil

Complications of Peptic Ulcer Disease

Complication	Incidence	Clinical Features	Management
Hemorrhage	15-20% of PUD patients	Hematemesis, melena, shock	Resuscitation, endoscopy (injection, clipping), surgery if persistent
Perforation	5-10% of PUD patients	Sudden severe epigastric pain, board-like rigidity, air under diaphragm	Resuscitation, antibiotics, surgery (oversewing + patch, resection)
Obstruction	2-5% of PUD patients	Vomiting, dehydration, metabolic alkalosis, succussion splash	NG decompression, IV fluids, PPI, endoscopic dilatation or surgery
Penetration	1-2% of PUD patients	Back pain (pancreas), jaundice (bile duct), change in pain pattern	Medical treatment, surgery if medical failure

Gastritis Classification

Type	Etiology	Location	Clinical Features
Acute Erosive	NSAIDs, alcohol, stress, burns (Curling’s), CNS injury (Cushing’s)	Diffuse, multiple erosions	Bleeding, epigastric pain
Chronic Superficial	H. pylori, autoimmune, bile reflux	Antrum (H. pylori), body (autoimmune)	Dyspepsia, risk of atrophy and cancer
Atrophic Gastritis	Long-standing H. pylori, autoimmune (pernicious anemia)	Body and fundus	Achlorhydria, B12 deficiency, increased cancer risk

Helicobacter pylori Infection

Prevalence: 50% of world population, higher in developing countries
Transmission: Fecal-oral, oral-oral, contaminated water
Pathogenesis: Urease production, VacA and CagA toxins, inflammation
Diagnosis:
- Non-invasive: Urea breath test, stool antigen, serology
- Invasive: Rapid urease test, histology, culture
Treatment: Triple therapy (PPI + clarithromycin + amoxicillin/metronidazole)

Gastric Tumors

Benign Gastric Tumors

Tumor Type	Frequency	Features	Management
Gastric Adenoma	Most common benign epithelial tumor	Usually in antrum, premalignant (30-40% risk)	Endoscopic resection, surveillance
Gastrointestinal Stromal Tumor (GIST)	Most common benign mesenchymal tumor	Submucosal, CD117 positive, variable malignant potential	Local excision with clear margins
Leiomyoma	Common benign smooth muscle tumor	Usually asymptomatic, may ulcerate and bleed	Excision if symptomatic or growing
Lipoma	Rare	Submucosal, yellow color on endoscopy	Excision if symptomatic

Gastric Carcinoma

Feature	Intestinal Type	Diffuse Type
Incidence	Decreasing worldwide	Stable or increasing
Age	Older adults (50-70 years)	Younger adults (30-50 years)
Geography	High in Japan, China, South America	Similar worldwide
Risk Factors	H. pylori, atrophic gastritis, dietary nitrites, smoking	Genetic (E-cadherin mutation), blood group A
Pathology	Gland formation, intestinal metaplasia	Signet ring cells, limits plastica
Location	Antrum (50%), lesser curvature	Body and fundus, diffuse involvement
Prognosis	Better, if detected early	Poor, early spread

Staging of Gastric Cancer (TNM 8th Edition)

Stage	T	N	M	5-year Survival
0	Tis	N0	M0	>90%
IA	T1	N0	M0	70-80%
IB	T2	N0	M0	60-70%
IIA	T3	N0	M0	40-50%
IIB	T1-2	N1	M0	30-40%
IIIA	T3-4a	N1	M0	20-30%
IIIB	T2-3	N2	M0	10-20%
IIIC	T4a	N3	M0	5-10%
IV	Any T	Any N	M1	<5%

Other Malignant Tumors

Tumor Type	Frequency	Features	Treatment
Gastric Lymphoma	5% of gastric malignancies	Usually NHL, MALT type associated with H. pylori	H. pylori eradication, chemotherapy, radiotherapy
GIST	1-2% of gastric malignancies	CD117 positive, variable malignant potential	Surgery, imatinib for metastatic disease
Carcinoid Tumors	Rare	Type I: Associated with atrophic gastritis, Type II: ZES, Type III: Sporadic	Endoscopic resection, antrectomy, formal resection

Gastric Surgery

Surgical Procedures for Peptic Ulcer Disease

Procedure	Technique	Indications	Complications
Truncal Vagotomy + Drainage	Division of main vagal trunks + pyloroplasty/gastrojejunostomy	Elective for DU, not commonly used now	Dumping, diarrhea, gallstones
Selective Vagotomy	Preserves hepatic and celiac branches	Historical, rarely used	Less diarrhea than truncal
Highly Selective Vagotomy	Denervates corpus and fundus only, preserves antral innervation	Elective DU without obstruction	Lower complication rate, higher recurrence
Vagotomy + Antrectomy	Vagotomy + distal 40% gastrectomy	Complicated PUD, gastric outlet obstruction	Dumping, diarrhea, nutritional deficiencies

Gastric Resection for Cancer

Procedure	Extent of Resection	Indications	Reconstruction
Distal Gastrectomy	Antrum and pylorus (50-60% stomach)	Distal gastric cancer	Billroth I, Billroth II, Roux-en-Y
Total Gastrectomy	Entire stomach, omentum, lymph nodes	Proximal cancer, limits plastica, extensive tumors	Roux-en-Y esophagojejunostomy
Proximal Gastrectomy	Cardia and proximal stomach	Early proximal cancers	Esophagogastrostomy
Wedged Resection	Local excision of tumor with margin	Early gastric cancer, benign tumors	Primary closure

Lymph Node Dissection in Gastric Cancer

Dissection	Nodes Removed	Indications	Survival Benefit
D1	Perigastric nodes (stations 1-6)	Early gastric cancer (T1)	Standard for early cancer
D2	D1 + nodes along left gastric, common hepatic, splenic arteries, celiac axis	Advanced gastric cancer (T2-4)	Improved survival in experienced centers
D3	D2 + para-aortic nodes	Selected cases in Japan	No proven survival benefit

Postgastrectomy Syndromes

Syndrome	Onset	Pathophysiology	Management
Dumping Syndrome	Early (30 min) or late (2-3 hours)	Rapid gastric emptying, hyperosmolar contents	Diet modification, acarbose, somatostatin
Afferent Loop Syndrome	Postprandial	Obstruction of afferent limb in Billroth II	Surgical revision to Roux-en-Y
Alkaline Reflux Gastritis	Weeks to months	Bile reflux damaging gastric mucosa	Medical therapy, Roux-en-Y conversion
Postvagotomy Diarrhea	Variable	Rapid intestinal transit, bile salt malabsorption	Diet, cholestyramine, codeine

References

Love, R. J. M., & Bailey, H. (Latest Edition). A Short Practice of Surgery. London: Edward Arnold.
Chapter on Gastric Diseases in Love & Bailey’s textbook
American College of Gastroenterology Guidelines
Japanese Gastric Cancer Association Guidelines
European Society for Medical Oncology (ESMO) Guidelines
National Comprehensive Cancer Network (NCCN) Guidelines

Key Learning Points from Love & Bailey

“The stomach, with its complex anatomy and physiology, presents unique surgical challenges. A thorough understanding of gastric blood supply, lymphatic drainage, and nerve supply is essential for safe and effective surgical management of both benign and malignant gastric conditions.”
- Love & Bailey, A Short Practice of Surgery

Important Clinical Pearls

Always test for H. pylori in peptic ulcer disease and gastric lymphoma
Early gastric cancer is often asymptomatic - maintain high index of suspicion
D2 lymphadenectomy improves survival in advanced gastric cancer when performed by experienced surgeons
Postgastrectomy syndromes can significantly impact quality of life
Nutritional support is crucial after major gastric surgery
Multimodal therapy is standard for locally advanced gastric cancer
Regular surveillance endoscopy is needed for high-risk conditions like gastric atrophy and adenomas

This educational blog is based on the surgical textbook “A Short Practice of Surgery” by Love and Bailey.

For medical professionals and students only. Always consult current guidelines and local protocols.