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Gastric stump adenocarcinoma

Gastric stump adenocarcinoma. Case report. Gastric stump adenocarcinoma. Male, 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

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Gastric stump adenocarcinoma

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  1. Gastric stump adenocarcinoma Case report

  2. Gastric stump adenocarcinoma • Male, 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

  3. Physical signs • General: underweight, palor, inelastic skin fold • Abdominal examination • Flat abdomen moving with respirations • Post. Op.scar- median xypho- ombilical • Moderate tenderness in epigastrium • Succusion splash • NG aspiration- 100o ml. Gastric fluid non-bile stained with undigested food

  4. 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

  5. Clinical diagnosis Cancer of the gastric stump ?

  6. Investigations • Lab. Tests- NAD except a moderate anemia • Barium 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 MTS • CXR- NAD

  7. Operative findings • Gastric stump tumour starting from the gastro-duodenal anastomosis • Invasion of the D1 and D2 • Perigastriclymphadenopathy • Liver and peritoneum intact

  8. What to do? • Frozen section from the a perigastric lymph node negative for tumour cells • Mobile tumour on adjacent planes • Age • Absent comorbidities

  9. Operative decision • Completion gastrectomy • D2 lymphadenectomy: loco-regional • Tactic splenectomy • Cephalic duodenopancreatectomy • Digestive continuity: • Eso-jejunal anastomosis • 60 cm distal to it- Wirsungo-jejunal anastomosis • 20 cm distal to it- biliary-jejunal anastomosis

  10. Case report • Operative time- 6 hours • Postoperative course- uneventful • Contrast medium eso-jejunal radiological check-up- intact anastomosis without any leak • Hospital stay- 26 days

  11. Pathology report of the surgical specimen • Polipoyd adenocarcinoma • Lymph nodes: perigastric, retroduodenal, celiac trunk, hilum of the spleen were negative for tumour cells • pTNM- T2 N0 M0

  12. 2003-1 year post-operatively • 10 Kg weight gain • Good digestive tolerance • Symptoms-free • Normal hematological and biochemistry tests

  13. Next post-operative course • 2005- acute appendicitis- appendectomy • 2007-routine endoscopic check-up • eso-jejunal anastomotic recurrence

  14. 2007- further investigations • Endoscopic biopsy- adenocarcinoma • CXR- NAD • Abdominal USS-slightly enlarged liver, pneumobilia, normal remnant pancreas, no ascites, no lombo-aortic lymph nodes • Respiratory tests- WNL

  15. 2007- further investigations • Barium meal: eso-jejunal anastomosis T-L, anastomotic lacunar image- 2cm in size • Abdominal CT- thickening at the level of the anastomosis with esophageal extent

  16. Barium meal- 2007

  17. What to do? • Surgical options: • Partial esophagectomy with intrathoracic graft interposition • Esophageal stripping with colic graft • Small eso-jejunal tumour • Absence of mediastinal lymph nodes-CT • Avoidance of left thoracotomy

  18. Decisions • Surgical resection • Esophageal stripping • Proximal jejunostomy • Digestive reconstruction • Left colon graft • Colo-jejunal anastomosis • Colo-colic anastomosis • Cervical eso-colic anastomosis • Nutrition • TPN • Jejunostomy tube

  19. Surgical specimenEsophagus and jejunum

  20. Pull-through esophagectomy

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

  22. Fungating tumour

  23. Left colon prepared as a graft for esophagus

  24. Pathology report • Colloid adenocarcinoma invading the digestive wall thickness till subserosa • 3 out of 4 jejunal mesentry limph nodes positive • Periesophageal lymph nodes negative

  25. Early morbidity • Cervical eso-colic fistula • Small output • Conservative treatment • Oral hygene • Spontaneous closure in 2 weeks • Radiological check-up before oral intake

  26. Eso-colic fistula-jan.2008

  27. Late morbidity • Colic fistula due to forcibly coughing episodes after quit smoking • Relaparotomy-transverse colon fistula • Colo-jejunal and colo-colic anastomoses intact • Coloraphy and abdominal drainage • Good recovery • Discharged after 9 days

  28. Abdominal scar

  29. Patent eso-colic anastomosis, may 2008

  30. Neck scar- left lateral

  31. Intact colo-jejunal anastomoses, may 2008

  32. After discharge

  33. january 2009 • Multiple pulmonary metastases

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