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Case report
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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
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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
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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
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Clinical diagnosis
Cancer of the gastric stump ?
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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
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Operative findingsGastric stump tumour starting from
the gastro-duodenal anastomosis
Invasion of the D1 and D2
Perigastric lymphadenopathy
Liver and peritoneum intact
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What to do?Frozen section from the a perigastric lymph
node negative for tumour cells
Mobile tumour on adjacent planes
Age
Absent comorbidities
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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
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Case reportOperative time- 6 hoursPostoperative course- uneventful
Contrast medium eso-jejunal radiological check-up- intact anastomosis without any leak
Hospital stay- 26 days
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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
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2003-1 year post-operatively
10 Kg weight gainGood digestive toleranceSymptoms-freeNormal hematological and biochemistry tests
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Next post-operative course2005- acute appendicitis- appendectomy
2007-routine endoscopic check-up
eso-jejunal anastomotic recurrence
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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
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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
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Barium meal- 2007
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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
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DecisionsSurgical resection
Esophageal strippingProximal jejunostomy
Digestive reconstructionLeft colon graftColo-jejunal anastomosisColo-colic anastomosisCervical eso-colic anastomosis
NutritionTPNJejunostomy tube
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Surgical specimenEsophagus and jejunum
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Pull-through esophagectomy
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Inner aspect of the anastomotic tumour (esophago-jejunal tumour)
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Fungating tumour
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Left colon prepared as a graft for esophagus
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Pathology report
Colloid adenocarcinoma invading the digestive wall thickness till subserosa
3 out of 4 jejunal mesentry limph nodes positive
Periesophageal lymph nodes negative
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Early morbidity
Cervical eso-colic fistulaSmall outputConservative treatmentOral hygeneSpontaneous closure in 2 weeksRadiological check-up before oral intake
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Eso-colic fistula-jan.2008
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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
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Abdominal scar
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Patent eso-colic anastomosis, may 2008
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Neck scar- left lateral
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Intact colo-jejunal anastomoses, may 2008
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After discharge
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january 2009Multiple pulmonary metastases