Case Report: Gastric tube cancer after esophagectomy - Retro
A 57-year-old patient developed a gastric tube adenocarcinoma after oncological esophagectomy of a squamous cell cancer. The squamous cell cancer was diagnosed in the mid third of the esophagus 6 years earlier, and its initial stage was T1bN0M0. It was treated via definitive chemoradiation at 60 Gy and chemotherapy with fluorouracil and cisplatin. The chemoradiation was performed according to the protocol of the JCOG 0502 study, which is an ongoing prospective study comparing esophagectomy with definitive chemoradiotherapy for T1bN0 cancers; it includes both randomized and patient preference arms [12]. The recurrence of tumor was suspected locally 2 years after treatment and was resected by performing thoracoscopic subtotal esophagectomy and two field-lymphadenectomy in a salvage setting. Reconstruction was accomplished via gastric pull-up through the retrosternal route and cervical anastomosis.

At the annual endoscopic follow-up 4 years after esophagectomy, a tumor was detected around the pylorus of the gastric conduit. The tumor was histologically diagnosed as an adenocarcinoma, and its clinical stage based on preoperative computed tomography (CT) and endoscopic ultrasound was cT3N1M0; hence, surgical resection was indicated. A single lymphatic metastasis was suspected in the infrapyloric lymph node (lymph node station number 6a according to the Japanese classification of gastric cancer). Preoperative CT showed that the tumor was entirely within the abdomen.

Resection of the proximal right gastroepiploic artery was necessary to achieve an adequate extent of lymphadenectomy, especially considering the suspected metastasis in the infrapyloric lymph node. Thus, we planned to perform distal partial resection of the gastric tube, followed by lymphadenectomy along and reconstruction of the right gastroepiploic artery. The right gastric artery was preserved during gastric tube resection. After proximal resection of the right gastroepiploic artery, the remnant vessel had visible retrograde pulsation, contrary to our expectation. The oral resection margin of the gastric wall had sufficient blood supply owing to retrograde perfusion. Because there was no sign of macroscopic ischemia for more than 20 minutes after resection of the right gastroepiploic artery, we decided to forego its reconstruction. Gastrointestinal reconstruction was performed by end-to-side gastroenterostomy in the Billroth II position.

The postoperative course was uncomplicated. Six days after surgery, the patient began oral intake of nutrients. Eleven days after surgery, the patient was fully recovered and discharged in good clinical condition. Based on postoperative histopathological examination of a surgical specimen, the pathological stage of the gastric tube tumor was pT3N1M0. A positive extranodal lymphatic metastasis was observed in the tissue along the right gastroepiploic artery (lymph node station number 4d, which is continuous with the infrapyloric lymph node). Three months after surgery, the patient was doing well without any sign of recurrence.

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