Resection of distal gastric tube cancer with sentinel node biopsy: a case report and review of the literature

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.

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.

Successful preservation of the proximal stomach tube by evaluating blood flow using indocyanine green for gastric tube cancer: a case report

BACKGROUND

There have been two reports on preserving the proximal gastric tube by using intraoperative indocyanine green (ICG)-based photodynamic detection to evaluate blood flow through the anastomosis for gastric tube cancer after esophagectomy. However, in those cases, the period since the first operation was > 3 years 11 months, and there have been no reports of cases with < 1-year periods after the first operation.

CASE PRESENTATION

A 59-year-old man underwent video-assisted thoracic subtotal esophagectomy and gastric tube reconstruction after two courses of preoperative chemotherapy for middle thoracic esophageal cancer. After half a year, follow-up upper gastrointestinal endoscopy showed a submucosal tumor in the posterior wall of the pre-pyloric region. We performed a biopsy, and the results led to a diagnosis of gastric cancer (moderately differentiated adenocarcinoma: tub2). Clinically, the patient was described as having stage IB (cT2N0M0) gastric cancer of the reconstructed gastric tube. To avoid total gastrectomy, we tried to evaluate the blood flow of the proximal part of the gastric tube by intraoperative ICG-based photodynamic detection. Intraoperative findings confirmed neo-vascularization from the remnant cervical esophagus to the upper region of the gastric tube approximately 7 cm through the esophagogastric anastomosis. Therefore, we dissected the distal part of the gastric tube approximately 4 cm from the esophagogastric anastomosis and then performed Roux-en-Y gastro-jejunostomy via the ante-sternum route. The postoperative course was stable, and the patient was discharged on the 14th postoperative day.

CONCLUSIONS

ICG-based photodynamic diagnosis was found to be simple and less invasive. Therefore, even if the postoperative period is short, this method should be considered for evaluation of blood flow prior to performing less invasive surgery.

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.

Pyloroantrectomy and Pedunculated Short Gastric-Tube Interposition in Esophageal Carcinoma Patients Associated With Early Gastric Adenocarcinoma

Gastric carcinoma is one of the most common secondary malignancies in esophageal cancer patients. We herein report our surgical procedure for esophageal reconstruction in esophageal cancer patients associated with synchronous or metachronous early gastric adenocarcinoma. Gastric adenocarcinoma was removed by pyloroantrectomy with preservation of the right gastroepiploic artery and vein, and a pedunculated short gastric tube was used as an esophageal substitute in a Roux-en-Y fashion. Surgical data of 6 esophageal cancer patients who underwent this type of surgery between 1993 and 2012 were analyzed. Three patients had synchronous early gastric carcinoma and the remaining 3 patients had metachronous early gastric adenocarcinoma. The gastric tube was easily pulled up to the neck and no problems occurred during this procedure. Postoperative complications, including leakage of esophagogastrostomy, acute respiratory failure, and diffuse peritonitis, were observed in 3 patients. No patients suffered from necrosis of the gastric tube. Although 3 patients died of other diseases, gastric cancer recurrence has not been observed to date. Despite the need for precaution to ensure technical safety, pyloroantrectomy and esophageal reconstruction using a pedunculated short gastric-tube are oncologically feasible as a potential curative surgery for esophageal cancer patients with early gastric adenocarcinoma.