Indian Journal of Surgery

, Volume 81, Issue 1, pp 70–76 | Cite as

A Comparison of Subtotal Gastrectomy and Total Gastrectomy for Distal Gastric Cancer

  • Enver Ilhan
  • Orhan UreyenEmail author
Review Article


Gastric cancer is one of the leading causes of cancer-related mortality worldwide, and surgery is the only curative treatment option for gastric cancer. Resection may be a preferable treatment option depending on the localization, size, and stage of the tumor. Comparative benefits of total and subtotal gastrectomy for the treatment of distal gastric cancers are still controversial. Total gastrectomy of distal gastric cancers is recommended based on the hypotheses that suggest that this procedure decreases the probability of recurrence, eliminates the multicentric cancer loci which may remain in the gastric tissue after subtotal gastrectomy, and rules out the possibility of remnant gastric cancer which may develop metachronously. However, studies that investigated the superiority of these two approaches to one another reported conflicting results regarding their effects on survival; while some studies showed comparable survival rates, others demonstrated the superiority of total or subtotal gastrectomy. Rates of postoperative mortality and morbidity associated with both procedures are also still controversial. Majority of the studies addressed in this review retrospectively evaluated subtotal or total gastrectomy procedures for the treatment of antrum or distal corpus gastric cancers. It is notable that a very limited number of randomized controlled studies that investigated these two procedures reported inconsistent results. Meta-analysis studies also remained insufficient to prove the superiority of one procedure to another. This controversial topic can only be clarified through randomized controlled trials that investigated the same surgical procedure in gastric cancer cases with similar histopathology and the same ethnic origin and clinical stage.


Stomach cancer Gastrectomy Postoperative complications Survival 





Randomized controlled trial


Total gastrectomy


Subtotal gastrectomy


Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.


  1. 1.
    Japanese Gastric Cancer Association (2017) Japanese gastric cancer treatment guidelines 2014 (ver. 4). Gastric Cancer 20:1–19. CrossRefGoogle Scholar
  2. 2.
    Dicken BJ, Bigam DL, Cass C, Mackey JR, Joy AA, Hamilton SM (2005) Gastric adenocarcinoma: review and considerations for future directions. Ann Surg 241:27–39Google Scholar
  3. 3.
    Stein HJ, Sendler A, Siewert JR (2002) Site-dependent resection techniques for gastric cancer. Surg Oncol Clin N Am 11:405–414CrossRefGoogle Scholar
  4. 4.
    Clark CJ, Thirlby RC, Picozzi V Jr, Schembre DB, Cummings FP, Lin E (2006) Current problems in surgery: gastric cancer. Curr Probl Surg 43:566–670CrossRefGoogle Scholar
  5. 5.
    Robertson CS, Chung SC, Woods SD, Griffin SM, Raimes SA, Lau JT, Li AK (1994) A prospective randomized trial comparing R1 subtotal gastrectomy with R3 total gastrectomy for antral cancer. Ann Surg 220:176–182CrossRefGoogle Scholar
  6. 6.
    Roukos D, Schmidt-Mathiesen A, Encke A (1995) Adenocarcinoma of the gastric antrum: does D2 total gastrectomy with splenectomy improve prognosis compared to D1 subtotal gastrectomy? A long-term survival analysis with emphasis on Lauren classification. Surg Oncol 4:323–332CrossRefGoogle Scholar
  7. 7.
    Egli S, Schlatter K, Streule R, Lage D (2006) A structure-based expert model of the ICD-10 mental disorders. Psychopathology 39(1):1–9CrossRefGoogle Scholar
  8. 8.
    Bozzetti F, Marubini E, Bonfanti G, Miceli R, Piano C, Gennari L (1999) Subtotal versus total gastrectomy for gastric cancer: five-year survival rates in a multicenter randomized Italian trial. Italian Gastrointestinal Tumor Study Group. Ann Surg 230(2):170–178CrossRefGoogle Scholar
  9. 9.
    Billroth T (1991) General surgical pathology and therapy. Guidance for students and physicians. Lecture. Khirurgiia (Mosk) 10:136–143 RussianGoogle Scholar
  10. 10.
    Lauren P (1965) The two histological main types of gastric carcinoma: diffuse and so-called intestinal-type carcinoma. An attempt at a histo-clinical classification. Acta Pathol Microbiol Scand 64:31–49CrossRefGoogle Scholar
  11. 11.
    Wanebo HJ, Kennedy BJ, Chmiel J, Steele G Jr, Winchester D, Osteen R (1993) Cancer of the stomach. A patient care study by the American College of Surgeons. Ann Surg 218(5):583–592CrossRefGoogle Scholar
  12. 12.
    Hundahl SA, Menck HR, Mansour EG, Winchester DP (1997) The National Cancer Data Base report on gastric carcinoma. Cancer 80(12):2333–2341CrossRefGoogle Scholar
  13. 13.
    Collins WT, Gall EA (1952) Gastric carcinoma, multicentric lesion. Cancer 5:62–72CrossRefGoogle Scholar
  14. 14.
    Suzuki H, Endo M, Nakayama K (1983) A review of the five-year survival rate and clinicopathologic factors in stomach cancer treated by surgery alone. Int Adv Surg Oncol 6:271–308Google Scholar
  15. 15.
    Yamamoto M, Yamanaka T, Baba H, Kakeji Y, Maehara Y (2008) The postoperative recurrence and the occurrence of second primary carcinomas in patients with early gastric carcinoma. J Surg Oncol 97(3):231–235CrossRefGoogle Scholar
  16. 16.
    Wu B, Wu D, Wang M, Wang G (2008) Recurrence in patients following curative resection of early gastric carcinoma. J Surg Oncol 98(6):411–414CrossRefGoogle Scholar
  17. 17.
    Braga M, Molinari M, Zuliani W, Foppa L, Gianotti L, Radaelli G, Cristallo M, Di Carlo V (1996) Surgical treatment of gastric adenocarcinoma: impact on survival and quality of life. A prospective ten year study. Hepatogastroenterology 43(7):187–193Google Scholar
  18. 18.
    Degiuli M, Sasako M, Ponti A (2010) Italian Gastric Cancer Study Group. Morbidity and mortality in the Italian Gastric Cancer Study Group randomized clinical trial of D1 versus D2 resection for gastric cancer. Br J Surg 97:643–649CrossRefGoogle Scholar
  19. 19.
    Gouzi JL, Huguier M, Fagniez PL, Launois B, Flamant Y, Lacaine F, Paquet JC, Hay JM (1989) Total versus subtotal gastrectomy for adenocarcinoma of the gastric antrum. A French prospective controlled study. Ann Surg 209(2):162–166CrossRefGoogle Scholar
  20. 20.
    Lortat-Jacob J, Giuli R, Estenne B, Clot P (1975) Value of total gastrectomy for treatment of cancers of the stomach. Study of 482 radical operations. Chirurgie 101(1):59–67 FrenchGoogle Scholar
  21. 21.
    McNeer G, Bowden L, Booner RJ, McPeak CJ (1974) Elective total gastrectomy for cancer of the stomach: end results. Ann Surg 180(2):252–256CrossRefGoogle Scholar
  22. 22.
    Gockel I, Pietzka S, Gonner U, Hommel G, Junginger T (2005) Subtotal or total gastrectomy for gastric cancer: impact of the surgical procedure on morbidity and prognosis – analysis of a 10-year experience. Langenbeck's Arch Surg 390(2):148–155CrossRefGoogle Scholar
  23. 23.
    Bradburn MJ, Deeks JJ, Berlin JA, Russell Localio A (2007) Much ado about nothing: a comparison of the performance of meta-analytical methods with rare events. Stat Med 26(1):53–77CrossRefGoogle Scholar
  24. 24.
    Imamura H, Takiguchi S, Yamamoto K, Hirao M, Fujita J, Miyashiro I, Kurokawa Y, Fujiwara Y, Mori M, Doki Y (2012) Morbidity and mortality results from a prospective randomized controlled trial comparing Billroth I and Roux-en-Y reconstructive procedures after distal gastrectomy for gastric cancer. World J Surg 36(3):632–637. CrossRefGoogle Scholar
  25. 25.
    Le A, Berger D, Lau M, El-Serag HB (2007) Secular trends in the use, quality, and outcomes of gastrectomy for noncardia gastric cancer in the United States. Ann Surg Oncol 14:2519–2527CrossRefGoogle Scholar
  26. 26.
    Kim DJ, Lee JH, Kim W (2015) Comparison of the major postoperative complications between laparoscopic distal and total gastrectomies for gastric cancer using Clavien-Dindo classification. Surg Endosc 29:3196–3204. CrossRefGoogle Scholar
  27. 27.
    Bozzetti F, Bonfanti G, Bufalino R, Menotti V, Persano S, Andreola S, Doci R, Gennari L (1982) Adequacy of margins of resection in gastrectomy for cancer. Ann Surg 196:685–690CrossRefGoogle Scholar
  28. 28.
    Jang YJ, Park MS, Kim JH, Park SS, Park SH, Kim SJ, Kim CS, Mok YJ (2010) Advanced gastric cancer in the middle one-third of the stomach: should surgeons perform total gastrectomy? J Surg Oncol 101:451–456Google Scholar
  29. 29.
    Smith JK, McPhee JT, Hill JS, Whalen GF, Sullivan ME, Litwin DE, Anderson FA, Tseng JF (2007) National outcomes after gastric resection for neoplasm. Arch Surg 142:387–393CrossRefGoogle Scholar
  30. 30.
    An JY, Youn HG, Choi MG, Noh JH, Sohn TS, Kim S (2008) The difficult choice between total and proximal gastrectomy in proximal early gastric cancer. Am J Surg 196:587–591.
  31. 31.
    Siewert JR, Botcher K, Roder JD, Bush R, Hermanek P, Meyer HJ (1993) Prognostic relevance of systematic lymph node dissection in gastric carcinoma. German Gastric Carcinoma Study Group. Br J Surg 80:1015–1018CrossRefGoogle Scholar
  32. 32.
    Roukos D, Paraschou P, Lorenz M (2000) Distal gastric cancer and extensive surgery: a new evaluation method based on the study of the status of residual lymph nodes after limited surgery. Ann Surg Oncol 7:719–726CrossRefGoogle Scholar
  33. 33.
    Piso P, Werner U, Lang H, Mirena P, Klempnauer J (2000) Proximal versus distal gastric carcinoma. What are the differences? Ann Surg Oncol 7:520–525CrossRefGoogle Scholar
  34. 34.
    Meyer HJ, Jahne J, Wilke H, Pichlmayr R (1991) Surgical treatment of gastric cancer: retrospective survey of 1,704 operated cases with special reference to total gastrectomy as the operation of choice. Semin Surg Oncol 7:356–364CrossRefGoogle Scholar
  35. 35.
    Hansson LE, Ekstrom AM, Bergstrom R, Nyren O (2000) Surgery for stomach cancer in a defined Swedish population: current practices and operative results. Swedish Gastric Cancer Study Group. Eur J Surg 166:787–795. CrossRefGoogle Scholar
  36. 36.
    Lee SE, Ryu KW, Nam BH, Lee JH, Kim YW, Yu JS, Kook MC (2009) Technical feasibility and safety of laparoscopy-assisted total gastrectomy in gastric cancer: a comparative study with laparoscopy-assisted distal gastrectomy. J Surg Oncol 100:392–395. CrossRefGoogle Scholar
  37. 37.
    Wu CW, Hsieh MC, Lo SS, Wang LS, Hsu WH, Lui WY, P'eng FK (1995) Morbidity and mortality after radical gastrectomy for patients with carcinoma of the stomach. J Am Coll Surg 181:26–32Google Scholar
  38. 38.
    Schumacher IK, Hunsicker A, Petermann J, Lorenz D (1999) Surgery of stomach carcinoma—established and controversial procedures. Retrospective 1-year analysis with discussion of current aspects. Chirurg 70:1447–1453CrossRefGoogle Scholar
  39. 39.
    Lau M, Le A, El-Serag HB (2006) Noncardia gastric adenocarcinoma remains an important and deadly cancer in the United States: secular trends in incidence and survival. Am J Gastroenterol 101:2485–2492CrossRefGoogle Scholar
  40. 40.
    Bozzetti F, Marubini E, Bonfanti G, Miceli R, Piano C, Crose N, Gennari L (1997) Total versus subtotal gastrectomy: surgical morbidity and mortality rates in a multicenter Italian randomized trial. The Italian Gastrointestinal Tumor Study Group. Ann Surg 226(5):613–620CrossRefGoogle Scholar
  41. 41.
    Morgagni P, Marfisi C, Gardini A, Marrelli D, Saragoni L, Roviello F, Vittimberga G, Garcea D (2009) Italian Research Group for Gastric Cancer. Subtotal gastrectomy as treatment for distal multifocal early gastric cancer. J Gastrointest Surg 13(12):2239–2244CrossRefGoogle Scholar
  42. 42.
    Mocan L, Tomus C, Bartos D, Zaharie F, Ioana I, Bartos A, Puia C, Necula A, Mocan T, Iancu C (2013) Long term outcome following surgical treatment for distal gastric cancer. J Gastrointestin Liver Dis 22:53–58Google Scholar
  43. 43.
    Liu Z, Huang B, Jin Y, Feng F, Sun L, Guo M, Lian X, Zhang H (2015) Distal gastrectomy brings a better long-term survival for patients with distal gastric cancer compared with total gastrectomy. Zhonghua Wei Chang Wai Ke Za Zhi 18(2):1240–1243Google Scholar
  44. 44.
    Lin JX, Huang CM, Zheng CH, Li P, Xie JW, Wang JB, Jun L, Chen QY, Lin M, Tu R (2016) Evaluation of laparoscopic total gastrectomy for advanced gastric cancer: results of a comparison with laparoscopic distal gastrectomy. Surg Endosc 30(5):1988–1998CrossRefGoogle Scholar
  45. 45.
    Moghimi M, Marashi SA, Salehian T, Peirovi H, Sodagari F (2008) Surgical outcomes and local recurrence following total or subtotal gastrectomy for early adenocarcinoma of antrum. Chin J Cancer Res 20:279–285CrossRefGoogle Scholar
  46. 46.
    Liu Z, Feng F, Guo M, Liu S, Zheng G, Xu G, Lian X, Fan D, Zhang H (2017) Distal gastrectomy versus total gastrectomy for distal gastric cancer. Medicine 96:5Google Scholar
  47. 47.
    De Manzoni G, Verlato G, Roviello F, Di Leo A, Marrelli D, Morgagni P, Pasini F, Saragoni L, Tomezzoli A (2003) Subtotal versus total gastrectomy for T3 adenocarcinoma of the antrum. Gastric Cancer 6(4):237–242CrossRefGoogle Scholar
  48. 48.
    Lee JH, Kim YI (2010) Which is the optimal extent of resection in middle third gastric cancer between total gastrectomy and subtotal gastrectomy? J Gastric Cancer 10(4):226–233CrossRefGoogle Scholar
  49. 49.
    Park S, Chung HY, Lee SS, Kwon O, Yu W (2014) Serial comparisons of quality of life after distal subtotal or total gastrectomy: what are the rational approaches for quality of life management? J Gastric Cancer 14(1):32–38CrossRefGoogle Scholar
  50. 50.
    Kong L, Yang N, Shi L, Zhao G, Wang M, Zhang Y (2016) Total versus subtotal gastrectomy for distal gastric cancer: meta-analysis of randomized clinical trials. Onco Targets Ther 9:6795–6800CrossRefGoogle Scholar
  51. 51.
    Qi J, Zhang P, Wang Y, Chen H, Li Y (2016) Does total gastrectomy provide better outcomes than distal subtotal gastrectomy for distal gastric cancer? A systematic review and meta-analysis. PLOS ONE 11(10):e0165179. CrossRefGoogle Scholar

Copyright information

© Association of Surgeons of India 2018

Authors and Affiliations

  1. 1.Izmir Bozyaka Training and Research Hospital, Department of General SurgeryUniversity of Health SciencesIzmirTurkey

Personalised recommendations