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CORRESPONDENCE
Year : 2018  |  Volume : 14  |  Issue : 9  |  Page : 538-541

Surgical treatment of esophageal carcinoma after distal partial gastrectomy: Case report and literature review


Department of Thoracic Surgery, Fu Xing Hospital of Capital Medical University, Beijing 100038, China

Date of Web Publication29-Jun-2018

Correspondence Address:
Su Chen
Department of Thoracic Surgery, Fu Xing Hospital of Capital Medical University, A 20# Street, Fuxingmenwai District, Xicheng, Beijing 100038
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.179164

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 > Abstract 

The objective of the study was to highlight the significance of surgical treatment for esophageal carcinoma after distal gastrectomy and provide suitable surgical options. A patient with esophageal carcinoma and previous distal partial gastrectomy was treated by replacing the esophagus with remnant stomach and moving the spleen into the thoracic cavity. We then systematically reviewed the literature on the treatment of such conditions. Postoperative recovery went well. During the 2-year follow-up, the patient did not complain any discomfort and had no signs of metastasis or recurrence. For esophageal carcinoma patients who have undergone distal gastrectomy, surgery should remain an option. For patients whose carcinoma is in the lower part of the esophagus or who are frail but had an early diagnosis, surgery to replace the esophagus with remnant stomach and relocation of the spleen into the thoracic cavity should be considered.

Keywords: Esophageal carcinoma, gastrectomy, surgery


How to cite this article:
Chen S, Huang N. Surgical treatment of esophageal carcinoma after distal partial gastrectomy: Case report and literature review. J Can Res Ther 2018;14, Suppl S2:538-41

How to cite this URL:
Chen S, Huang N. Surgical treatment of esophageal carcinoma after distal partial gastrectomy: Case report and literature review. J Can Res Ther [serial online] 2018 [cited 2019 Nov 18];14:538-41. Available from: http://www.cancerjournal.net/text.asp?2018/14/9/538/179164


 > Introduction Top


Esophageal carcinoma often develops in patients who undergo distal partial gastrectomy and surgical treatment is complex. Following a distal partial gastrectomy, the stomach loses most of its blood supply and conventional surgical treatment of replacing the esophagus with the stomach tends to affect the anastomotic healing between the remnant stomach and the esophagus. As a result, in most cases, the esophagus is replaced with a portion of the colon.

Recently, we encountered such a patient where we shaped the remnant stomach into a tubular shape and performed aortic arch anastomosis between the lower esophagus and the remnant stomach. There was no separation between the spleen and stomach, and the spleen was moved into the thoracic cavity. We then reviewed related literature and summarized the surgical procedures used to treat such patients.


 > Case Report Top


A 48-year-old man was admitted due to choking and vomiting after eating. On endoscopy, we observed a space-occupying lesion with surface ulceration, on the esophagus, 32–37 cm from the incisors [Figure 1]. Twenty years before, due to gastric perforation, a gastric Billroth II gastrectomy was performed at a different hospital [Figure 2]. A biopsy was obtained, and examination revealed esophageal squamous cell carcinoma [Figure 3].
Figure 1: Space-occupying lesion with surface ulceration of the esophagus 32–37 cm from the incisors, revealed by endoscopy, in a 48-year-old man

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Figure 2: Results of preoperative gastric and jejunal angiography. Twenty years before, the patient had undergone a gastric Billroth II gastrectomy

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Figure 3: A biopsy was obtained, and examination revealed esophageal squamous cell carcinoma

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Under general anesthesia, a left thoracoabdominal incision and esophagectomy were performed, followed by tube angioplasty of the remnant stomach, esophageal gastric tube aortic arch anastomosis, relocation of the spleen to the thoracic cavity [Figure 4], and lymph node dissection in the mediastinum and the abdomen. Following surgery, the patient underwent conventional treatment, recovered well, and was discharged after 10 days. After 2 years, follow-up review showed no obvious abnormalities [Figure 5] and [Figure 6].
Figure 4: During surgery, the spleen was moved to the thoracic cavity

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Figure 5: Results of postoperative upper gastrointestinal radiography

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Figure 6: Postoperative computed tomographic observation: (a) lower end of spleen; (b) gate area of spleen; and (c) upper end of spleen

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 > Literature Review Top


Postdistal partial gastrectomy esophageal carcinoma

Postdistal partial gastrectomy esophageal carcinoma is also known as remnant stomach esophageal cancer. It refers to primary malignant esophageal mucosa tumor more than 5 years after a gastrectomy resulting from a benign disease of the stomach or duodenum or early gastric cancer.[1]

Treatment of postdistal partial gastrectomy esophageal carcinoma

Since remnant stomach esophageal carcinoma is a primary malignant esophageal mucosa tumor, postoperative survival time is similar to that of common esophageal primary tumor, and the conventional treatment is surgery. However, since surgery is difficult to perform in such cases, nonsurgical methods of treatment are often used.[2]

Treatment of esophageal cancer after gastric resection

The key to the treatment of remnant stomach esophageal cancer is to replace the esophagus after excision.[3] Upon reviewing the literature, we concluded that three types of surgical procedures are used to treat remnant stomach esophageal carcinoma:

  1. Remnant stomach replaces the esophagus: In this procedure, the key to success is protecting the remnant stomach blood supply [4] and preventing incomplete postoperative anastomotic healing due to poor blood circulation. Splenectomy inside the splenic gateway can be used to protect the blood supply. In addition, the length of the resection can be a problem. The length of the resection can be extended by releasing the pancreas tail or turning the stomach tube upside down. However, this surgical technique is not a suitable option to treat esophageal cancer in the upper, mid thorax, or the neck region
  2. Colon replaces the esophagus: Considered the ideal surgery, this is the most common surgical method used to treat such patients. It can be used in the upper and mid thorax and neck region resections.[4],[5],[6] However, this procedure also has several disadvantages. First, since the surgical trauma is significant, it is not suitable for frail patients. Second, since upper abdominal surgery has been performed, abdominal adhesions may affect the blood supply of the transplanted colon and finally, the rate of incidence of anastomotic fistula is high. In addition, surgery drastically alters the anatomy which often leads to poor quality of life [7],[8],[9],[10]
  3. The jejunum replaces the esophagus: In recent years, reports have discussed using the jejunum to replace the esophagus. In these cases, the rate of anastomotic fistulas was significantly lower than that of using the colon to replace the esophagus. Its advantage is that the blood supply to the jejunum is better than that to the colon. However, the limited length of the transplants and poor acid resistance of the jejunum limit the use of this technique.



 > Discussion Top


Following partial gastrectomy, the blood supply mainly consists of circulation between the stomach and the spleen. Therefore, surgery is extremely difficult in patients who receive a diagnosis of esophageal carcinoma following a partial gastrectomy. The difficulty is maintaining a good blood supply and optimizing the length of the resection.

In this case, the blood vessels between the stomach and spleen remained intact. We cut the remnant stomach into a tubular shape, loosened the splenic pedicle and periphery of the spleen, moved the spleen into the thoracic cavity, and attached the tubular-shaped stomach to the esophagus. One feature of this surgical technique is that there is no separation between the stomach and the spleen, so the stomach maintains a blood supply.

In this surgery, we noted the following:

  1. Surgical indications: This procedure is not indicated in all patients. First, the size of the remnant stomach determines the length of the tubular stomach; therefore, a small remnant stomach is not suitable for this surgery. Patients with lower esophageal carcinoma may be considered for this type of surgery while patients with upper and middle esophageal carcinoma are not candidates for this procedure. In addition, if the tumor is longer than 5 cm, surgical procedures will likely leave residues, which make these patients unsuitable candidates. In addition, this procedure is less invasive than other techniques, which makes it especially appropriate for frail elderly patients
  2. Surgery notes: Because splenic blood vessels might be deformed during the esophageal reconstruction, the reconstruction should be appropriately accommodative to prevent the reconstructed opening from pressing against the blood vessels. To prevent postoperative diaphragmatic hernia, abdominal pressure should not be too high; this is especially true for patients with constipation or prostatic hypertrophy
  3. In addition, because the stomach and spleen occupy a large space on the left side of the thorax, patients with poor cardiopulmonary function are not suitable for this surgery
  4. Before this surgical procedure, the colon should also be prepared to replace the esophagus
  5. After surgery, left thoracentesis should be avoided to prevent injury to the spleen. Physicians should inform patients that because the spleen is in the thorax, left thoracic impact should be avoided to prevent splenic injury.



 > Conclusions Top


For esophageal cancer patients who have undergone gastrostomy, surgery should remain an option. For most patients, replacing the esophagus with the colon can be considered. However, for patients with a tumor in the lower esophagus or who have poor health, replacing the esophagus with remnant stomach and moving the spleen into the thorax can be considered.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
 > References Top

1.
Wang Q, Liu J, Zhao X, Lei J, Cong Q, Li W, et al. Can esophagogastric anastomosis prevent gastroesophageal reflux. Zhonghua Wai Ke Za Zhi 1999;37:71-3, 3.  Back to cited text no. 1
    
2.
Cheng BC, Xia J, Mao ZF, Huang J, Wang ZW, Wang TS, et al. Surgery for upper or middle thoracic esophageal carcinoma after gastrectomy. Zhonghua Wai Ke Za Zhi 2005;43:909-12.  Back to cited text no. 2
    
3.
Nègre E, Chardenon P, Caporiccio A, Giordan J. Cancers of the thoracic esophagus in gastrectomized patients. Technical problems. J Chir (Paris) 1975;110:217-24.  Back to cited text no. 3
    
4.
Shao LF, Gao ZR, Wei GQ, Xu JL, Chen MY, Cheng JH. Surgical treatment of carcinoma of the esophagus and gastric cardia: A 42-year investigation. Chin J Surg 2001;39:44-6.  Back to cited text no. 4
    
5.
Hofstetter W, Swisher SG, Correa AM, Hess K, Putnam JB Jr., Ajani JA, et al. Treatment outcomes of resected esophageal cancer. Ann Surg 2002;236:376-84.  Back to cited text no. 5
    
6.
Hüttl TP, Wichmann MW, Geiger TK, Schildberg FW, Fürst H. Techniques and results of esophageal cancer surgery in Germany. Langenbecks Arch Surg 2002;387:125-9.  Back to cited text no. 6
    
7.
Awsakulsutthi S, Havanond C. A retrospective study of anastomotic leakage between patients with and without vascular enhancement of esophageal reconstructions with colon interposition: Thammasat University Hospital experience. Asian J Surg 2015;38:145-9.  Back to cited text no. 7
    
8.
Greene CL, DeMeester SR, Augustin F, Worrell SG, Oh DS, Hagen JA, et al. Long-term quality of life and alimentary satisfaction after esophagectomy with colon interposition. Ann Thorac Surg 2014;98:1713-9.  Back to cited text no. 8
    
9.
Kesler KA, Pillai ST, Birdas TJ, Rieger KM, Okereke IC, Ceppa D, et al. “Supercharged” isoperistaltic colon interposition for long-segment esophageal reconstruction. Ann Thorac Surg 2013;95:1162-8.  Back to cited text no. 9
    
10.
Fürst H, Hüttl TP, Löhe F, Schildberg FW. German experience with colon interposition grafting as an esophageal substitute. Dis Esophagus 2001;14:131-4.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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