Management of synchronous adenocarcinoma of the esophago-gastric junction and ampulla of Vater: case report of a surgically challenging condition

Successful staged surgery for advanced esophageal cancer after conversion pancreatoduodenectomy with pancreaticogastrostomy

BACKGROUND

Complex surgery during initial cancer treatment can limit surgical options when planning management of a secondary malignancy. Subtotal esophagectomy and pancreatoduodenectomy are the most invasive and difficult procedures in gastroenterological surgery. Surgical cases in which subtotal esophagectomy was performed after pancreatoduodenectomy with pancreaticogastrostomy are extremely rare and challenging procedures due to the resulting complicated anatomical changes.

CASE PRESENTATION

A 60-year-old man with a history of conversion pancreatoduodenectomy with pancreaticogastrostomy for advanced pancreatic head cancer was diagnosed as having advanced thoracic esophageal squamous cell carcinoma. After neoadjuvant chemotherapy, we chose a two-staged surgery with thoracoscopic subtotal esophagectomy. Following percutaneous endoscopic gastrostomy, we performed subtotal esophagectomy, systematic lymph-node dissection, and esophagostomy as the first-stage operation. Fifty-six days later, we performed gastrointestinal reconstruction with pedicle jejunum and microvascular anastomosis by the percutaneous route as the second-stage operation. Postoperatively, the patient was relieved without major complications, and the tumors were amenable to curative pathologic resection.

CONCLUSIONS

The greatest advantages of staged surgery are to reduce surgical invasiveness and to circumvent the lower rate of curability. Our procedure reported here may be recommended as an option for staged resection and reconstruction in patients with advanced esophageal cancer after pancreatoduodenectomy with pancreaticogastrostomy.

Combined two-stage total pancreatoduodenectomy and esophagectomy for synchronous malignancy of the pancreatic corpus and the esophagus: A surgical case report

INTRODUCTION

Synchronous visceral malignancy is rare especially for esophagogastric junction adenocarcinoma combined with malignancy in the pancreas. So far only 7 cases of combined partial pancreatoduodenectomy and esophagectomy for synchronous malignancy have been described in the literature and none for combined total pancreatectomy and esophagectomy.

PRESENTATION OF CASE

We report the case of a 67-year-old male patient, who underwent multi-modality treatment including two-stage total pancreatoduodenectomy and subsequent Ivor-Lewis esophagectomy for synchronous adenocarcinoma of the distal esophagus and pancreatic multilocal metastases of a renal cell carcinoma after nephrectomy 17 years ago. Pathology revealed R0 resections for both malignancies and there were no postoperative complications. A 12 months follow-up showed no signs of recurrence and a good quality of life.

CONCLUSION

Curative-intent, combined oncological two-stage open total pancreatoduodenectomy and esophagectomy with several days interval is safe and feasible in selected cases when performed by an experienced interdisciplinary team in a high-volume surgical center.

Combined one-stage esophagectomy and duodeno-pancreatectomy for synchronous cancers of the esophagus and pancreatic ampulla in an elderly patient

BACKGROUND

We report the case of a 77-year-old patient, who underwent multi-modality treatment including single-stage radical oesophagectomy and duodeno-pancreatectomy for a synchronous adenocarcinoma of the distal oesophagus and adenocarcinoma of the ampulla of Vater.

METHODS

The ampulloma was diagnosed incidentally during the work-up of the symptomatic esophageal cancer. After induction chemo-radiation of the oesophageal cancer (CROSS regimen), a single-stage radical resection of the esophagus, total gastrectomy and a cephalic duodeno-pancreatectomy was performed. Intestinal reconstruction was done by a right coloplasty with esophago-colic anastomosis in the upper chest and distally to the Roux-en-Y (Child) used for reconstruction of the hepato-biliary tract. Adjuvant chemotherapy was proposed due to the unexpectedly advanced stage of the ampullary cancer (pT4N1M0) and was completed uneventfully despite the magnitude of the preceding surgery.

RESULTS

According to our literature review, this is the first report of a successfully completed tri-modality treatment with combined single-stage oesophagectomy and Whipple procedure in an elderly (>75 years). Functional and metabolic outcome was satisfactory until cancer recurrence due to liver metastasis of bilio-pancreatic origin. The patient is alive 2 years post-operatively.

CONCLUSION

Single-stage radical resection of the oesophagus and a cephalic duodeno-pancreatectomy can be more considered for synchronous cancers even in elderly patient.

Successful minimally invasive two-stage operation for rare synchronous cancers of the esophagus and the pancreatic head: A case report

We report the case of a 70-year-old woman with synchronous advanced esophageal cancer and pancreatic head cancer. To reduce the surgical invasiveness, we performed a two-stage operation that included percutaneous endoscopic gastrostomy and minimally invasive esophagectomy. In the first stage, we performed a percutaneous endoscopic gastrostomy, a thoracoscopic esophagectomy with cervical and mediastinal lymph node dissection, and an esophagostomy without a laparotomy. The second stage, which was performed 28 days after the first operation, consisted of a total gastrectomy, pancreaticoduodenectomy, colonic reconstruction, and jejunostomy. Fifty days after the second operation, the patient was discharged from the hospital. A two-stage operation that includes minimally invasive esophagectomy seems to be useful for avoiding serious postoperative complications, even in patients with rare, synchronous advanced cancers of the esophagus and the pancreatic head.

Synchronous resection of esophageal cancer and other organ malignancies: A systematic review

BACKGROUND

Neoplasms arising in the esophagus may coexist with other solid organ or gastrointestinal tract neoplasms in 6% to 15% of patients. Resection of both tumors synchronously or in a staged procedure provides the best chances for long-term survival. Synchronous resection of both esophageal and second primary malignancy may be feasible in a subset of patients; however, literature on this topic remains rather scarce.

AIM

To analyze the operative techniques employed in esophageal resections combined with gastric, pancreatic, lung, colorectal, kidney and liver resections and define postoperative outcomes in each case.

METHODS

We conducted a systematic review according to PRISMA guidelines. We searched the Medline database for cases of patients with esophageal tumors coexisting with a second primary tumor located in another organ that underwent synchronous resection of both neoplasms. All English language articles deemed eligible for inclusion were accessed in full text. Exclusion criteria included: (1) Hematological malignancies; (2) Head/neck/pharyngeal neoplasms; (3) Second primary neoplasms in the esophagus or the gastroesophageal junction; (4) Second primary neoplasms not surgically excised; and (5) Preclinical studies. Data regarding the operative strategy employed, perioperative outcomes and long-term outcomes were extracted and analyzed using descriptive statistics.

RESULTS

The systematic literature search yielded 23 eligible studies incorporating a total of 117 patients. Of these patients, 71% had a second primary neoplasm in the stomach. Those who underwent total gastrectomy had a reconstruction using either a colonic (n = 23) or a jejunal (n = 3) conduit while for those who underwent gastric preserving resections (i.e., non-anatomic/wedge/distal gastrectomies) a conventional gastric pull-up was employed. Likewise, in cases of patients who underwent esophagectomy combined with pancreaticoduodenectomy (15% of the cohort), the decision to preserve part of the stomach or not dictated the reconstruction method (whether by a gastric pull-up or a colonic/jejunal limb). For the remaining patients with coexisting lung/colorectal/kidney/liver neoplasms (14% of the entire patient population) the types of resections and operative techniques employed were identical to those used when treating each malignancy separately.

CONCLUSION

Despite the poor quality of available evidence and the great interstudy heterogeneity, combined procedures may be feasible with acceptable safety and satisfactory oncologic outcomes on individual basis.

Effects of transthoracic vs transabdominal hiatal approaches for treatment of esophago-gastric junction adenocarcinoma

AIM: To compare the effects of transthoracic and transabdominal hiatal approaches for the treatment of Siewert types Ⅱ and Ⅲ adenocarcinoma of the esophago-gastric junction.

METHODS: A total of 350 patients who were pathologically diagnosed with Siewert type Ⅱ or type Ⅲ adenocarcinoma of the esophago-gastric junction and underwent surgical treatment at our hospital were included, of whom 148 received surgery via the transthoracic approach (transthoracic group) and 202 received surgery via transabdominal hiatal approach (transabdominal hiatal group). Intraoperative parameters, postoperative recovery and complications were compared between the two groups of patients.

RESULTS: The number of patients receiving multi-visceral resection was more in the transabdominal hiatal group than in the transthoracic group (χ² = 12.744, P = 0.002), but the operative time, intraoperative blood loss, length of esophageal resection and number of patients receiving transfusion were lower in the transabdominal hiatal group (P = 0.039, 0.011, 0.009, 0.000). Postoperative pain score and antibiotic use duration in the transthoracic group were significantly higher than those in the transabdominal hiatal group (t = 5.879, 9.388, P = 0.005, 0.000), and the length of hospital stay, postoperative hospitalization cost, reoperation, and readmission rate showed the same trend (P = 0.027, 0.021, 0.048, 0.025). Although the rates of abdominal cavity infection and anastomotic stenosis showed no statistical differences between the two groups (χ² = 1.524, 0.149, P = 0.217, 0.700), the rates of lung infection, postoperative bleeding and anastomotic leakage were significantly higher in the transthoracic group than in the transabdominal hiatal group (χ² = 9.031, 9.031, 4.215, P = 0.003, 0.040, 0.024).

CONCLUSION: Patients with type Ⅱ or Ⅲ adenocarcinoma of the esophago-gastric junction treated via the transabdominal hiatal approach suffered from less intraoperative trauma and had quicker recovery and lower incidence of complications.

Management of synchronous tumours of the oesophagus and pancreatic head: a novel approach

Synchronous tumours of the oesophagus and pancreatic head are very rare. This report describes a unique case of an adenocarcinoma of the distal oesophagus and a neuroendocrine tumour of the pancreatic head diagnosed synchronously but successfully managed metachronously. Initially, the patient underwent an oesophagectomy, with a colonic reconstruction following some months later by pylorus-preserving pancreaticoduodenectomy. A staged resection was performed after a review of the literature suggested increased morbidity with synchronous major abdominal operations.