1. 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

8. Operative findings Gastric stump tumour starting from the gastro-duodenal anastomosis Invasion of the D1 and D2 Perigastric lymphadenopathy Liver and peritoneum intact

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

10. 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

12. 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

13. 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

14. 2003-1 year post-operatively 10 Kg weight gain Good digestive tolerance Symptoms-free Normal hematological and biochemistry tests

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

16. 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

17. 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

18. Barium meal- 2007

19. 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

20. 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

21. Surgical specimen Esophagus and jejunum

22. Pull-through esophagectomy

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

24. Fungating tumour

25. Left colon prepared as a graft for esophagus

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

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

28. Eso-colic fistula-jan.2008

29. 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

30. Abdominal scar

31. Patent eso-colic anastomosis, may 2008

32. Neck scar- left lateral

33. Intact colo-jejunal anastomoses, may 2008

34. After discharge

35. january 2009 Multiple pulmonary metastases