Case report

Gastric stump adenocarcinomaMale, MV, 56-year of age, retired brick

mason

2002- 3 months history of epigastric pain, vomiting after meals, asthenia, weight loss

Habits: smoking, heavy alcohol drinking

PMH- partial gastric resection for gastric ulcer-20 years ago

Physical signsGeneral: underweight, palor, inelastic skin

fold

Abdominal examinationFlat abdomen moving with respirationsPost. Op.scar- median xypho- ombilicalModerate tenderness in epigastriumSuccusion splash

NG aspiration- 100o ml. Gastric fluid non-bile stained with undigested food

What is the clinical suspicion?Previous partial gastric resection- stump

problem

Frequent vomiting- undigested food- stenosis

Anemia- chronic blood loss

Weight loss- bad nutrition

Succusion splash- stenosis

Clinical diagnosis

Cancer of the gastric stump ?

InvestigationsLab. Tests- NAD except a moderate anemiaBarium meal- partial gastric resection Billroth

I, gastric stump dilated, desorganized mucosal folds

Endoscopy- stenotic gastro-duodenal anastomosis , multiple gastro-duodenal polyps

Biopsy- adenocarcinoma of the gastric stump of papillary type

Abdominal USS- absent liver MTSCXR- NAD

Operative findingsGastric stump tumour starting from

the gastro-duodenal anastomosis

Invasion of the D1 and D2

Perigastric lymphadenopathy

Liver and peritoneum intact

What to do?Frozen section from the a perigastric lymph

node negative for tumour cells

Mobile tumour on adjacent planes

Age

Absent comorbidities

Operative decisionCompletion gastrectomyD2 lymphadenectomy: loco-regionalTactic splenectomyCephalic duodenopancreatectomyDigestive continuity:

Eso-jejunal anastomosis60 cm distal to it- Wirsungo-jejunal

anastomosis20 cm distal to it- biliary-jejunal anastomosis

Case reportOperative time- 6 hoursPostoperative course- uneventful

Contrast medium eso-jejunal radiological check-up- intact anastomosis without any leak

Hospital stay- 26 days

Pathology report of the surgical specimenPolipoyd adenocarcinomaLymph nodes: perigastric, retroduodenal, celiac trunk, hilum of the spleen were negative for tumour cells

pTNM- T2 N0 M0

2003-1 year post-operatively

10 Kg weight gainGood digestive toleranceSymptoms-freeNormal hematological and biochemistry tests

Next post-operative course2005- acute appendicitis- appendectomy

2007-routine endoscopic check-up

eso-jejunal anastomotic recurrence

2007- further investigations

Endoscopic biopsy- adenocarcinomaCXR- NADAbdominal USS-slightly enlarged

liver, pneumobilia, normal remnant pancreas, no ascites, no lombo-aortic lymph nodes

Respiratory tests- WNL

2007- further investigationsBarium meal: eso-jejunal anastomosis T-L, anastomotic lacunar image- 2cm in size

Abdominal CT- thickening at the level of the anastomosis with esophageal extent

Barium meal- 2007

What to do?Surgical options:

Partial esophagectomy with intrathoracic graft interposition

Esophageal stripping with colic graftSmall eso-jejunal tumourAbsence of mediastinal lymph nodes-CT

Avoidance of left thoracotomy

DecisionsSurgical resection

Esophageal strippingProximal jejunostomy

Digestive reconstructionLeft colon graftColo-jejunal anastomosisColo-colic anastomosisCervical eso-colic anastomosis

NutritionTPNJejunostomy tube

Surgical specimenEsophagus and jejunum

Pull-through esophagectomy

Inner aspect of the anastomotic tumour (esophago-jejunal tumour)

Fungating tumour

Left colon prepared as a graft for esophagus

Pathology report

Colloid adenocarcinoma invading the digestive wall thickness till subserosa

3 out of 4 jejunal mesentry limph nodes positive

Periesophageal lymph nodes negative

Early morbidity

Cervical eso-colic fistulaSmall outputConservative treatmentOral hygeneSpontaneous closure in 2 weeksRadiological check-up before oral intake

Eso-colic fistula-jan.2008

Late morbidity

Colic fistula due to forcibly coughing episodes after quit smoking

Relaparotomy-transverse colon fistulaColo-jejunal and colo-colic anastomoses intactColoraphy and abdominal drainageGood recoveryDischarged after 9 days

Abdominal scar

Patent eso-colic anastomosis, may 2008

Neck scar- left lateral

Intact colo-jejunal anastomoses, may 2008

After discharge

january 2009Multiple pulmonary metastases