Ann Thorac Surg 2006;81:751-753
© 2006 The Society of Thoracic Surgeons
How to do it
Treating Gastric Tube Cancer With Distal Gastrectomy Preserving the Gastroepiploic Artery
Satoru Motoyama, MD
*
,
Reijiro Saito, MD,
Manabu Okuyama, MD,
Kiyotomi Maruyama, MD,
Jun-ichi Ogawa, MD
Department of Surgery, Akita University School of Medicine, Akita, Japan
Accepted for publication November 10, 2004.
* Address correspondence to Dr Motoyama, Department of Surgery, Akita University School of Medicine, 1–1–1 Hondo, Akita 010–8543, Japan (Email: motoyama{at}doc.med.akita-u.ac.jp).
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Abstract
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Total resection of the gastric tube with lymphadenectomy is standard and reliable treatment for gastric tube cancer. However the risk associated with totally removing a gastric tube previously reconstructed through the posterior mediastinal route is significant, given the need to lyse a significant number of adhesions in order to reach the mediastinum. As a less invasive procedure, we used distal gastrectomy to treat superficial gastric tube cancer in 2 patients. The distal gastric tube was mobilized and resected with preservation of the right gastroepiploic artery, and the Roux-en-Y gastrojejunostomy was used for reconstruction. This procedure was curative with less surgical stress.
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Introduction
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The use of the stomach as an esophageal substitute has become a well-established surgical treatment procedure for esophageal cancer [1]. Recent advances in the treatment of esophageal cancer have afforded a better prognosis, resulting in an increased attention being focused on postoperative function and incidence of a second malignancy in the reconstructed gastric tube [2, 3]. Reconstruction through the posterior mediastinum is the most physiologic route and provides the greatest ease of swallowing; consequently the frequency with which the posterior mediastinal route is used is increasing. On the other hand, resection of a gastric tube that was previously reconstructed through the posterior mediastinal route is a lengthy procedure that induces severe surgical stress and considerable blood loss as a result of adhesions to and the invasion of important surrounding structures [4–7]. As a less invasive procedure, we recently used distal gastrectomy in which the right gastroepiploic artery was preserved in the treatment of superficial gastric tube cancer.
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Technique
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Patient 1
In April of 2000, a 71-year-old man, who had received subtotal esophagectomy with extended lymph node dissection and reconstruction with the gastric tube through the posterior mediastinal route 48 months earlier in our hospital, presented with a superficial (submucosal) gastric cancer that was limited to the pre-pyloric portion of the stomach (Fig 1A). Contrast enhanced computed tomography showed no regional lymph node swelling. Endoscopic mucosal resection was not indicated, given the depth of the tumor. Notably the patient also had severe obstructive pulmonary disease. Therefore we performed a distal resection of the gastric tube. With an upper median laparotomy, the distal gastric tube was mobilized and resected with preservation of the right gastroepiploic artery and vein, which respectively fed and drained the gastric tube; reconstruction was accomplished using the Roux-en-Y gastrojejunostomy. Lymph nodes were dissected along the right gastroepiploic artery to within the abdominal approach. The duration of the operation was 9 hours and 3,235 mL of blood were lost. The patient had mild aspiration pneumonia on postoperative day 5, though he was well soon thereafter. Histologic examination confirmed a well-differentiated adenocarcinoma of the gastric tube, which had invaded the submucosal layer (pT1N0M0, stage IA). The patient is doing well 55 months after surgery without recurrence.
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Fig 1. (A) Preoperative fluoroscopic findings and (B) postoperative reconstruction features in patient 1.
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Patient 2
In July of 2004, a 75-year-old man, who had received esophagectomy and reconstruction with the gastric tube through the posterior mediastinal route 61 months earlier, presented with a superficial (mucosal) gastric cancer located in the distal gastric tube at the level of the hiatus (Fig 2). Contrast-enhanced computed tomography showed no regional lymph node swelling. Endoscopic mucosal resection was not indicated, given the size of the tumor (60 mm in diameter) and the fact that the gastric tube could not be inflated with air due to its location at the hiatus. Therefore we performed a distal resection of the gastric tube. With an upper median laparotomy and left thoracotomy between the sixth and seventh ribs, the distal gastric tube was mobilized and resected with preservation of the right gastroepiploic artery and vein; reconstruction was accomplished using the Roux-en-Y gastrojejunostomy. Lymph node dissection was performed only along the gastric wall. The duration of the operation was 7.5 hours, and 1,001 mL of blood were lost. Histologic examination confirmed a poorly differentiated adenocarcinoma of the gastric tube, which had invaded the mucosal layer (pT1N0M0, stage IA). The patient is doing well 4 months after surgery.
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Comment
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Total resection of the gastric tube with lymph node dissection appears to be a reliable treatment for advanced gastric tube cancer. However, many surgeons claim the risk associated with totally removing a gastric tube that was previously reconstructed through the posterior mediastinal route is significant because of the difficulty of lysing adhesions [3–7]. Although there have been several reported cases of successful total resection enabling 5-year survival, including our two cases [3, 5], massive intraoperational blood loss or fatal pyothorax were observed in unsuccessful cases [4]. In our hospital, the entire gastric tube has been removed from 4 patients in the treatment of gastric tube cancer, and of these, 2 subsequently received reconstructive surgery. The average duration of those operations was 13.1 hours, the operative blood loss was 4,927 mL, the average hospital stay was 130 days, and 1 patient died in the hospital. These data demonstrate that total resection of the gastric tube with lymph node resection is much more invasive than the two cases of distal resection described here, in which the average duration of surgery was 8.3 hours, the operative blood loss was 2,118 mL, the average hospital stay was 40 days, and there were no deaths in the hospital. What accounts for this difference is that we did not have to perform the lysing necessary to reach the mediastinum. With the left thoracotomy approach there was no adhesion of the pleura, making it relatively easy to reach the mediastinum. On the other hand, preservation of the right gastroepiploic vessels despite lymph node dissection around them is quite difficult and requires patience and care to remove adhesions with the surrounding tissue without damaging the vessels.
Moreover, the surgical strategy must take into consideration the nature of the cancer. Both curative effect and surgical stress should determine the operative procedure. Gastric tube cancers are commonly located in the antrum [3], making it appropriate to resect the distal gastric tube in some cases. When distal gastrectomy is performed, and the proximal gastric tube is preserved, the right gastroepiploic artery must also be preserved to maintain the blood supply. In fact, one reported case of distal resection of the gastric tube without preservation of the blood supply led to ischemic changes in the mucosa [8]. In our first case, a well differentiated adenocarcinoma invaded the submucosa. So that the operation would be curative, we resected for removal of the lymph nodes along the right gastroepiploic artery to within the abdominal approach. The patient has survived more than 4 years, indicating that the extent of lymph node dissection was appropriate. In the second case, a poorly differentiated adenocarcinoma invaded the mucosa at the level of the hiatus. Therefore we performed a distal resection of the gastric tube with a laparotomy and left thoracotomy, preserving the right gastroepiploic artery and vein without lymph node dissection. We believe that this procedure is indicated for a stage IA gastric tube cancer located in the distal portion of the gastric tube. With mucosal gastric tube cancers, it is not always necessary to dissect the regional lymph nodes around the gastroepiploic vessels, but it should be done for submucosal cancers [9]. This approach may be somewhat less appropriate for more advanced gastric tube cancers when the patient is in poor general condition.
In summary, with the operative approach described here, our 2 patients received curative surgery with less stress, and the right gastroepiploic artery and vein were preserved. Thus, distal gastrectomy preserving the right gastroepiploic vessels, with or without lymph node dissection, can be indicated in cases of superficial gastric tube cancer.
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References
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- Akiyama H, Miyazono H, Tsurumaru M, Hashimoto C, Kawamura T. Use of the stomach as an esophageal substitute Ann Surg 1978;188:606-610.[Medline]
- Motoyama S, Saito R, Kitamura M, Ogawa J. Outcome of active surgery during intensive follow-up for second primary malignancy after esophagectomy for thoracic squamous cell esophageal carcinoma J Am Coll Surg 2003;197:914-920.[Medline]
- Motoyama S, Saito R, Kitamura M, et al. Prospective endoscopic follow-up results of reconstructed gastric tube Hapato-Gastroenterol 2003;50:666-669.
- Motoyama S, Kitamura M, Kamata S, Suzuki H, Sekine S, Ogawa J. Severe aspiration pneumonia after surgery for reconstructed gastric tube cancer treated with extracorporeal support Jpn J Thorac Cardiovasc Surg 1999;47:394-397.[Medline]
- Suzuki H, Kitamura M, Saito R, Motoyama S, Ogawa J. Cancer of the gastric tube reconstructed through the posterior mediastinal route after radical surgery for esophageal cancer Jpn J Thorac Cardiovasc Surg 2001;49:466-469.[Medline]
- Akita H, Doki Y, Ishikawa O, et al. Total removal of the posterior mediastinal gastric conduit due to gastric cancer after esophagectomy J Surg Oncol 2004;85:204-208.[Medline]
- Okamoto N, Ozawa S, Kitagawa Y, Shimizu Y, Kitajima M. Metachronous gastric carcinoma from a gastric tube after radical surgery for esophageal carcinoma Ann Thorac Surg 2004;77:1189-1192.[Abstract/Free Full Text]
- Yoshida T, Nagahama T, Maruyama M, Ebuchi M. Endoscopic comparison of two casesdistal resection of reconstructed gastric tube. Hepatogastroenterol 2002;49:371-374.
- Yokota T, Ishiyama S, Saito T, Teshima S, Shimotsuma M, Yamauchi H. Treatment strategy of limited surgery in the treatment guidelines for gastric cancer in Japan Lancet Oncol 2003;4:423-428.[Medline]
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Abstract
Introduction
