Gastric conduit cancer after oesophagectomy for oesophageal cancer: incidence and clinical implications

Comparative analysis of the outcomes of gastrectomy vs. endoscopic mucosal resection or endoscopic submucosal dissection for the treatment of gastric tube cancer after esophagectomy

This study investigated the clinical characteristics of patients with gastric tube cancer following esophagectomy at our hospital, and to examine the outcomes of gastrectomy versus endoscopic submucosal dissection. Of 49 patients who underwent treatment for gastric tube cancer that developed 1 year or more after esophagectomy, 30 patients underwent subsequent gastrectomy (Group A), and 19 patients underwent endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) (Group B). The characteristics and outcomes of these two groups were compared. The interval between esophagectomy and diagnosis of gastric tube cancer ranged from 1 to 30 years. The most common location was the lesser curvature of the lower gastric tube. When the cancer was detected early, EMR or ESD was performed, and the cancer did not recur. In advanced tumors, gastrectomy was performed but the gastric tube was difficult to approach and lymph node dissection was difficult; two patients died as a result of the gastrectomy. In Group A, recurrence occurred most often as axillary lymph node, bone, or liver metastases; in Group B, no recurrence or metastases were observed. In addition to recurrence and metastasis, gastric tube cancer is often observed after esophagectomy. The present findings highlight the importance of early detection of gastric tube cancer after esophagectomy and that the EMR and ESD procedures are safe and have significantly fewer complications compared with gastrectomy. Follow-up examinations should be scheduled with consideration given to the most frequent sites of gastric tube cancer occurrence and the time elapsed since esophagectomy.

Gastric Conduit Cancer following Ivor-Lewis Esophagectomy for Esophageal Adenocarcinoma: A Case Report and Literature Review

The incidence of gastric cancer associated with esophageal cancer is notably high. In recent years, there has been an increase in patients with gastric conduit cancers due to early detection and radical treatment of esophageal cancer, leading to prolonged survival of the patients. Metachronous gastric cancer following esophagectomy sometimes can pose a clinical challenge for surgeons, while gastric tube reconstruction is a well-established procedure accompanying esophagectomy, treating gastric cancer within the gastric tube can be difficult in contrast. Surgical treatment of gastric tube cancers is often complex and life-threatening. Early detection of gastric tube cancer is crucial for improving prognosis as it allows for less invasive surgical interventions. However, no specific guidelines for detecting gastric tube cancer have been established. In this report, we present a case of gastric tube cancer in a patient that had Ivor-Lewis surgery 20 years ago for preinvasive adenocarcinoma of the thoracic esophagus against the background of Barrett's esophagus. Recommendations for earlier and more accurate diagnosis and treatment of this pathology are discussed.

Influence of Preoperative Nutritional Status on Patients Who Undergo Upfront Surgery for Esophageal Squamous Cell Carcinoma

Few studies have focused on preoperative nutritional status of esophageal cancer patients eligible for upfront surgery. We aimed to investigate the association of preoperative nutritional status with prognosis of patients who undergo upfront surgery for esophageal cancer. A total of 274 patients who underwent upfront surgery for esophageal squamous cell carcinoma between January 2012 and December 2016 were eligible. Preoperative nutritional status was evaluated using prognostic nutritional index (PNI) scoring system, nutritional risk screening 2002 (NRS 2002), and controlling nutritional status. The median age was 63 years (interquartile range, 58-70) and 94.7% of patients were male. The pathological stages were Stage I-74.5% (204/274), Stage II-20.4% (56/274), and Stage III-5.1% (14/274). Multivariate analysis revealed that advanced stage, a low PNI, and a high NRS 2002 were independent predictors of overall survival. During median follow-up period of 55 mo, overall survival rates were lower in the high NRS 2002 group (P < 0.001). A high NRS 2002 score was associated with frequent postoperative complications, especially pneumonia and anastomosis site leakage (P = 0.003). The poor preoperative nutritional status with a high NRS 2002 is associated with postoperative complications as well as poor overall survival in patients with upfront surgery for esophageal cancer.Supplemental data for this article is available online at https://doi.org/10.1080/01635581.2022.2042573.

Operative outcomes and long-term survival of patients undergoing colon interposition after esophagectomy for cancer

Background

The first choice of an esophageal substitute after esophagectomy for cancer is the stomach. However, the colon must be considered for reconstruction in specific situations. The purpose of this study was to clarify the frequency and clinical features of patients who underwent colon interposition in thoracic esophagectomy and to investigate the postoperative complications and survival.

Methods

We conducted a retrospective case–control study in the National Cancer Center Hospital East, Japan. Patients who underwent colon interposition after esophagectomy for cancer between 2010 and 2020 were analyzed.

Results

Eighty‐eight patients underwent esophagectomy with colon interposition; 53.2% received preoperative treatment and 52.3% underwent thoracoscopic surgery. Clavien–Dindo grade >III postoperative complications occurred in 42% of the patients; anastomotic leakage was the most common complication, occurring in 26.1% of the cases. Univariate analysis of the factors associated with Clavien–Dindo grade <III complications showed that the period 2015–2020 and totally mechanical Collard anastomosis were significant factors, with odds ratios (OR) of 0.264 and 0.267 (p = 0.00327 and p = 0.00335), respectively. Totally mechanical Collard anastomosis was associated with a lower risk of anastomotic leakage by univariate and multivariate analysis (OR, 0.257, p = 0.00566 and OR, 0.285, p = 0.133, respectively). Three‐year overall survival was 54.2%. Univariate and multivariate analysis of overall survival showed that older age was a risk factor (OR, 1.08) for complications.

Conclusion

In colon reconstruction after esophageal cancer resection, totally mechanical Collard anastomosis for cervical anastomosis may reduce the risk of Clavien–Dindo grade >III complications.

Distal gastric tube resection with preservation of the right gastroepiploic artery for gastric tube cancer: a case report

Background

The incidence of gastric tube cancer is increasing because of improved survival rates in patients with esophageal cancer treated by esophagectomy. Total resection of the gastric tube is expected to be highly curative, but it is associated with a higher risk of severe postoperative complications. Herein we report a case of early gastric tube cancer that was successfully treated by distal gastric tube resection with preservation of the right gastroepiploic artery (RGEA).

Case presentation

An 82-year-old man was diagnosed as having gastric tube cancer, B-12-O, Type 0-IIc, T1b, N0, M0, cStage IA (Japanese Classification of Gastric Carcinoma). Upper gastrointestinal endoscopy showed a Type 0-IIc lesion measuring 30 mm in length in the lower part of the gastric tube, and histopathological examination of biopsy specimens revealed the features of poorly differentiated adenocarcinoma. The primary lesion could not be identified by computed tomography, and there was no obvious lymph node metastasis or distant metastasis. Considering that total resection of the gastric tube would have been highly invasive and that the gastric tube cancer was at a relatively early stage, we performed distal gastric tube resection with preservation of the RGEA. The postoperative course was uneventful, and the patient was discharged on postoperative day 12. There has been no recurrence during the 17 months of follow-up.

Conclusion

We successfully treated a patient with gastric tube cancer by distal gastric tube resection with preservation of the RGEA. This treatment strategy may be acceptable for patients with early gastric tube cancer without lymph node metastasis, considering the balance between the surgical invasiveness and curability of the tumor.

Metachronous carcinoma of the gastric tube following tumour-associated oesophagectomy

INTRODUCTION

The prognosis of oesophageal carcinoma has improved during the last years. Thereby, the increasing survival has led to increasing occurrence of secondary gastric tube carcinoma (gastric conduit cancer, GTC) following oesophageal tumour resection.

MATERIAL AND PATIENTS

A literature review (EMBASE, PubMed), spanning the years 2000 to 2020, identified 342 patients worldwide with a GTC following tumour-related oesophagectomy, of which 306 patients could be included for further analysis.

RESULTS

The median age of 306 patients with GTC was 66.4 (39-80) years. 91.2% of patients (n = 279) were male. The median interval between oesophagectomy and GTC was 60.3 (4-236) months. 73.8% of patients (n = 226) were diagnosed as early cancer (EGC, T1) and 26.2% as advanced carcinoma (AGC, > T2; n = 80). Primary oesophagectomy was performed in 97.4% of patients (N = 298) for squamous cell carcinoma. AEG I carcinoma was present in only 5 patients (1.6%). In contrast, 99% (n = 303) of the GTC were found to be adenocarcinomas. One hundred eighty patients (58.8%) could be treated by endoscopic resection (ER). R0 resection was achieved in 82.8% (n = 149). The complication rate was 13.3% (n = 24) and the 30-day mortality 1.1% (n = 2) for ER. Eighty-three patients (27.1%) were treated surgically. These included 13 wedge resections, 25 partial resections and 45 total gastric graft resections with predominantly colon interposition. The R0 rate was 98.8% (n = 82). The postoperative morbidity was 24.1% (n = 20); the 90-day mortality was 6% (n = 5). In 43 patients (14%), palliative chemotherapy or radiotherapy or best supportive care took place. GTC diagnosed early in the EGC stage can be safely managed with ER. In cases of advanced GTC, surgical resection can be a potentially curative approach. Survival times of up to 120 months have been described after intervention for GTC.

Management and outcomes of resectable gastric conduit cancer: a retrospective comparative study of 51 cases

PURPOSE

Although gastric conduit cancer (GCC) arising after esophagectomy is increasingly being reported, therapeutic strategies for resectable GCC have yet to be optimized. We investigated clinicopathological features of patients undergoing endoscopic versus more invasive surgical treatments for GCC and compared their outcomes.

METHODS

Fifty-one patients, who had a history of esophagectomy with gastric conduit reconstruction for esophageal cancer and underwent resection for metachronous GCC, were identified. Their characteristics and outcomes were retrospectively reviewed.

RESULTS

There were 48 males and three females, ranging in age from 46-86 years. Twelve patients underwent surgery for GCC (group S) and 39 underwent only endoscopic resection (group E). The most common cause of death was pneumonia (10/51, 19.6%). Neither overall survival nor cumulative incidence of pneumonia-caused death differed significantly between the two groups (P = 0.60, 0.84, respectively). In group S, partial gastrectomy was performed in four cases and total gastrectomy in seven. Partial resections, including three antrectomy without sternotomy or intrathoracic procedures, were completed with significantly shorter operative durations than total resections (median 208 vs 513 min, P = 0.012). GCC recurrence was experienced in two cases: one undergoing open approach partial resection of the corpus and the other thoracoscopic total gastrectomy.

CONCLUSION

Even compared with endoscopic treatment, outcomes following surgery for GCC appeared to be acceptable. Open approach total gastric gastrectomy could be the most radical modality, while other less invasive alternatives, e.g., antrectomy, are also an option. Clinicians may select a treatment strategy balancing radicality and patient status, reflecting tolerance to invasive procedures.

Distal gastrectomy for early gastric conduit carcinoma after Ivor-Lewis esophagectomy

A metachronous neoplasm can develop in a gastric conduit used for reconstruction after esophagectomy for thoracic esophageal cancer. Surgical resection is sometimes necessary to treat this neoplasm. We report a method for performing minimally invasive gastrectomy with preservation of the proximal residual stomach through laparotomy for cancer in the distal side of gastric conduit after Ivor-Lewis esophagectomy. Furthermore, Roux-en-Y reconstruction was performed after gastrectomy. This minimally invasive partial gastrectomy for early gastric conduit cancer and followed Roux-en-Y reconstruction may lead to a favorable clinical outcome.

Distal gastric tube resection with vascular preservation for gastric tube cancer: A case report and review of literature

BACKGROUND

Survival rates in patients with esophageal cancer undergoing esophagectomy have improved, but the prevalence of gastric tube cancer (GTC) has also increased. Total resection of the gastric tube with lymph node dissection is considered a radical treatment, but GTC surgery is more invasive and involves a higher risk of severe complications or death, particularly in elderly patients.

CASE SUMMARY

We report an elderly patient with early GTC that had invaded the duodenum who was successfully treated with resection of the distal gastric tube and Roux-en-Y (R-Y) reconstruction. The tumor was a type 0-IIc lesion with ulcer scars surrounding the pyloric ring. Endoscopic submucosal resection was not indicated because the primary lesion was submucosally invasive, was undifferentiated type, surrounded the pyloric ring, and had invaded the duodenum. Resection of distal gastric tube with R-Y reconstruction was safely performed, with preservation of the right gastroepiploic artery (RGEA) and right gastric artery (RGA).

CONCLUSION

Distal resection of the gastric tube with preservation of the RGEA and RGA is a good treatment option for elderly patients with cT1bN0 GTC in the lower part of the gastric tube.

Subtotal gastrectomy for gastric tube cancer using intraoperative indocyanine green fluorescence method

INTRODUCTION

Currently, the frequency of evaluating the flow of a reconstructed gastric tube using indocyanine green (ICG) fluorescence has been increasing. However, it has been difficult to decide on the operation method for patients with gastric tube cancer (GTC). We herein report a case in which ICG was effective in a patient with resection of GTC.

PRESENTATION OF CASE

An 83-year-old man underwent subtotal esophagectomy with gastric tube reconstruction via the retrosternal route for esophageal cancer and right hemicolectomy for ascending colon cancer 16 years earlier. Postoperatively, the proximal part of the gastric tube had poor blood flow. Therefore, the patient underwent proximal-side resection of the gastric tube. Thereafter, free jejunal graft reconstruction was performed. The patient had not developed recurrence at that point. Recently, the patient visited the hospital complaining of nausea and chest discomfort. Upper gastrointestinal endoscopy revealed a type 0-IIa + IIc lesion located around the pylorus. A biopsy showed adenocarcinoma. Based on these findings, the patient was diagnosed with gastric tube cancer (cT1bN0M0StageI). The invasion depth of the cancer was predicted to be widespread submucosal invasion. Therefore, the patient underwent surgery. Intraoperatively, we evaluated the flow of the gastric tube after clamping the right gastroepiploic artery using ICG fluorescence. As a result, the flow of the gastric tube was deemed insufficient. Consequently, subtotal gastrectomy was performed with preservation of the right gastroepiploic artery via Roux-en-Y reconstruction.

DISCUSSION

ICG fluorescence is useful for evaluating the flow of the gastric tube helping to decide the operating method.

CONCLUSION

We herein report a case of subtotal gastrectomy for GTC using intraoperative ICG fluorescence.

Gastric tube cancer after esophagectomy for cancer: a systematic review

Gastric conduit used for reconstruction after esophagectomy for cancer has the potential to develop a metachronous neoplasm known as gastric tube cancer (GTC). The aim of this study was to review literature and evaluate outcomes and possible treatment strategies for GTC. A comprehensive systematic literature search was conducted using PubMed, EMBASE, Scopus, and the Cochrane Library Central Register of Controlled Trials. No restriction was set for the type of publication, number, age, or sex of the patients. The search was limited to articles in English. Characteristics of esophageal cancer (EC) and its treatment and GTC and its treatment were analyzed. A total of 28 studies were analyzed, 12 retrospective analyses and 16 case reports, involving 229 patients with 250 GTCs in total. The majority of ECs (88.2%) were squamous cell carcinomas. In 120 patients (52.4%) a posterior mediastinal reconstructive route was used when esophagectomy was performed. The mean interval between esophagectomy and diagnosis of GTC was 55.8 months, with a median interval of 56.8 months (4-236 months). One hundred and twenty-four GTCs (49.6%) were located in the lower part of the gastric tube. One hundred and forty patients were endoscopically treated. Eighty-five patients underwent surgery. Thirty-six total gastrectomies with lymphadenectomy with colon or jejunal interposition were performed. Forty-three subtotal gastrectomies and 6 wedge resections were performed. The main reported postoperative complications were anastomotic leak, vocal cord palsy, and respiratory failure. Twenty-five patients were treated with palliative chemotherapy. Three-year survival rates were 69.3% for endoscopically treated patients, 58.8% for surgically resected patients, and 4% for patients who underwent palliative treatment. The feasibility of endoscopic resections in patients diagnosed with superficial GTC has been reported. Surgical treatment represented the preferred treatment method in operable patients with locally invasive tumor. Patients treated with conservative therapy have a scarce prognosis. The development of GTC should be taken into consideration during the extended follow-up of patients undergoing esophagectomy for cancer. Total gastrectomy plus lymphadenectomy should be considered the preferred treatment modality in operable patients with locally invasive tumor, when endoscopy is contraindicated. Long-term yearly endoscopic follow-up is recommended.

Case report: Gastric tube cancer after esophagectomy-Retrograde perfusion after proximal resection of right gastroepiploic artery

INTRODUCTION

We report a case of a 57-year-old patient with gastric tube cancer after subtotal esophagectomy and retrosternal gastric pull up.

CASE PRESENTATION

The patient developed gastric cancer 4 years after undergoing treatment for esophageal squamous cell cancer; the treatments included thoracoscopic subtotal esophagectomy, gastric pull-up reconstruction via a retrosternal route in salvage setting following definitive chemoradiation. Because the gastric tube cancer was located around the pylorus, transabdominal partial resection, which is much less invasive than total resection via sternotomy, was performed. During surgery, retrograde pulsation of the proximally resected right gastroepiploic artery was observed. Owing to an ample blood supply to the oral remnant of the gastric tube, vascular reconstruction of the right gastroepiploic artery was omitted. The postoperative recovery was eventless.

DISCUSSION

The right gastroepiploic artery is considered essential for blood supply to the gastric tube. However, there was no sign of ischemia after proximal resection of this artery, which suggests the vasculature was altered after gastric tube construction.

CONCLUSION

This case shows that partial distal resection of the gastric tube can be performed safely without vascular reconstruction of the right gastroepiploic artery. Favorable long-term results after gastric tube reconstruction support the possibility of bilateral blood supply to the gastroepiploic arcade.

Esophageal reconstruction by colon interposition after esophagectomy for cancer analysis of current indications, operative outcomes, and long-term survival

INTRODUCTION

Colon interposition is an alternative solution for esophageal reconstruction if the stomach cannot be used. The study reviews current indications and results of coloplasty for cancer.

METHODS

Patients who underwent colon interposition for gastro-esophageal malignancy were included. Primary coloplasty was defined as upfront colon interposition. Salvage coloplasty was defined as colon interposition after primary reconstruction failure. Mortality, morbidity, function, and survival were evaluated.

RESULTS

We included 28 patients (24 men, median age 61 years). Ten (36%) patients underwent primary coloplasty due to previous gastrectomy (n = 5), conduit gastric cancer (n = 2), extensive gastroesophageal involvement (n = 2), and gastric cancer recurrence (n = 1). Salvage coloplasty was performed in 18 (64%) patients for postoperative graft necrosis (n = 5) and intractable strictures (n = 3). Operative mortality, morbidity, and graft necrosis rates were 14% (4/28), 86% (24/28), and 14% (4/28), respectively; there were no significant differences between primary and salvage coloplasty. Survival rates at 1-, 3-, and 5 years were 81%, 51%, and 38%, respectively. Survival was decreased after primary coloplasty when compared to salvage coloplasty (P = 0.03). Nine patients experienced tumor recurrence (primary: n = 6, salvage: n = 3) after coloplasty and eight of them died.

CONCLUSION

Colon interposition after esophagectomy is a useful but morbid endeavor. Colon interposition as salvage therapy is associated with improved survival compared to its use as primary esophageal replacement, and colon interposition in the latter cohort should be used with caution due to poor cancer-specific survival in this patient population.