A case of gastric adenocarcinoma extirpated with total gastrectomy involving jejunal pouch reconstruction

Mohan Nayak Guguloth; Sai Kiran Kuchana; Tarun Kumar Suvvari; Anthony Reddy Gopu; Rohith Kode

doi:10.4103/am.am_134_21

CASE REPORT

Year : 2022 | Volume : 19 | Issue : 1 | Page : 59-61

A case of gastric adenocarcinoma extirpated with total gastrectomy involving jejunal pouch reconstruction

Mohan Nayak Guguloth¹, Sai Kiran Kuchana¹, Tarun Kumar Suvvari², Anthony Reddy Gopu¹, Rohith Kode¹
¹ Department of General Surgery, Kakatiya Medical College, Warangal, Telangana, India
² Dr. NTR University of Health Sciences, Vijayawada, Andhra Pradesh, India

Date of Submission	14-Nov-2021
Date of Decision	28-Jan-2022
Date of Acceptance	01-Feb-2022
Date of Web Publication	24-Feb-2022

Correspondence Address:
Tarun Kumar Suvvari
Dr. NTR University of Health Sciences, Vijayawada, Andhra Pradesh
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/am.am_134_21

Abstract

Gastric adenocarcinoma usually has a poor prognosis due to its late diagnosis in most cases. Gastric adenocarcinomas account for 95% of all malignant tumors of the stomach. In this report, we described a case of a 63-year-old man who presented with pain in the epigastric region for 1 month which was associated with hematemesis and loss of appetite. The upper gastrointestinal endoscopy (UGIE) revealed an ulcer of size 3 cm × 3 cm in the lesser curvature of the stomach. The patient underwent open total gastrectomy, dissection D2, and a jejunal pouch of 30 ml additional capacity was created 20 cm distal to duodenojejunal flexure and passed retrocolic from a rent in transverse mesocolon. The patient was sent to chemoradiotherapy after the surgery and discharged on the 24^th day after surgery. Postoperative biopsy revealed tumor tissue showing irregular, ill-defined, and glandular clouding with loss of polarity. Infiltration was up to the muscularis layer and mesenteric lymph nodes showed partial effacement of architecture with reactive changes and few multinucleated foreign body giant cells confirming the diagnosis as poorly differentiated adenocarcinoma of the stomach of II B class (T2 N2 M0) as per the Union for International Cancer Control guidelines.

Keywords: Gastric adenocarcinoma, jejunal pouch reconstruction, open total gastrectomy

How to cite this article:
Guguloth MN, Kuchana SK, Suvvari TK, Gopu AR, Kode R. A case of gastric adenocarcinoma extirpated with total gastrectomy involving jejunal pouch reconstruction. Apollo Med 2022;19:59-61

How to cite this URL:
Guguloth MN, Kuchana SK, Suvvari TK, Gopu AR, Kode R. A case of gastric adenocarcinoma extirpated with total gastrectomy involving jejunal pouch reconstruction. Apollo Med [serial online] 2022 [cited 2022 May 22];19:59-61. Available from: https://www.apollomedicine.org/text.asp?2022/19/1/59/338426

Introduction

Gastric carcinoma was commonly seen during the fifth to seventh decades of life.^[1] About 90% of all tumors are malignant in which adenocarcinomas account for 95% of all malignant tumors of the stomach.^[2] The potential curative approach for patients with gastric carcinoma is their early detection through screening and radical resection, most commonly a total or subtotal gastrectomy with accompanying lymphadenectomy.^[3],[4]

The American Joint Committee on Cancer and the Union for International Cancer Control (UICC) classifications are effectively used for analyzing the stage of cancer and determining the best treatment modality.^[5] The reconstruction modalities include Roux-en-Y esophagojejunostomy and jejunal pouch reconstruction. The latter was found to be more effective and better for patient compliance.^[6]

In patients with localized gastric adenocarcinoma, the 5-year survival is roughly 10% only. Long-term survival in patients with gastric carcinoma is closely related to the stage of disease and its anatomical location.^[7],[8]

Case Report

A 63-year-old male patient presented with pain in the epigastric region for 1 month which was insidious in onset, progressive in nature, and aggravated during nights. It was also associated with hematemesis, loss of appetite, and melena.

On physical examination, there was tenderness in the right hypochondrium. The workup included the UGIE which revealed an ulcer of size 3 cm × 3 cm [Figure 1] in the lesser curvature of the stomach. Endoscopy-guided biopsy revealed poorly differentiated, diffusely infiltrating atypical cells having moderate pleomorphism with an eccentric nucleus and abundant pale cytoplasm suggestive of poorly differentiated adenocarcinoma.

Figure 1: An ulcer of size 3 × 3 in the lesser curvature of the stomach removed by surgical resection

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The patient was thoroughly investigated radiologically to rule out metastasis, and then the patient was electively undertaken for surgery after improving nutritional status. The patient underwent open total gastrectomy, dissection D2, and jejunal pouch of 30 ml additional capacity was created 20 cm distal to duodenojejunal flexure and passed retrocolic from a rent in transverse mesocolon [Figure 2]. The jejunal pouch was anastomosed to the distal esophageal stump by esophagojejunostomy and jejunojejunostomy was done 10 cm distal to the former.

Figure 2: Open total gastrectomy was performed and a jejunal pouch of 30 ml additional capacity was created the jejunal pouch was anastomosed to the distal esophageal stump by esophagojejunostomy and finally jejunojejunostomy was done

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Postoperative biopsy revealed tumor tissue showing irregular, ill-defined, and glandular clouding with loss of polarity. Individual cells showed marked nuclear atypia with ill-defined cell margins and few signet ring cells [Figure 3]. Infiltration was up to the muscularis layer and mesenteric lymph nodes showed partial effacement of architecture with reactive changes and few multinucleated foreign body giant cells confirming the diagnosis as poorly differentiated adenocarcinoma of the stomach of II B class (T2 N2 M0) as per the UICC guidelines [Figure 4].

Figure 3: Tumor tissue showing irregular, ill-defined, and glandular clouding with loss of polarity and individual cells showing marked nuclear atypia with ill-defined cell margins and few signet ring cells

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Figure 4: Infiltration can be seen up to muscularis layer and mesenteric lymph nodes showed partial effacement and few multinucleated foreign body giant cells confirming the diagnosis as poorly differentiated adenocarcinoma of stomach

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The postoperative period was uneventful. The patient was sent to chemoradiotherapy and discharged on the 24^th day after surgery. The patient was followed up for 3 months and is still under follow-up and there were no complaints. The patient has not undergone any neoadjuvent chemotherapy.

Discussion

Gastric carcinoma is the fourth most common malignancy worldwide and remains the second cause of death of all malignancies worldwide.^[1] The age commonly presented being early 50s and 60s with a male preponderance. The development of endoscopic techniques has improved the proportion of gastric cancers detected at an early stage and hence decreasing cancer-related morbidity. It allows direct visualization of tumor location, mucosal involvement, and biopsy for tissue diagnosis.^[9],[10] In our case, we first worked on UGIE and confirmed the diagnosis by a guided biopsy.

The surgical resection procedure in resectable gastric cancers is determined by the location and size of the lesion and is also achievable free of margin of tissue after resection.^[1] In a study conducted by Heberer G et al., in Europe, he demonstrated that 44% of surgeons prefer total gastrectomy for improved tumor clearance and decrease the recurrence rate.^[11]

The involvement of regional lymph nodes ranges from 3% to 5% of tumors extending to the mucosa, 16% to 25% in cases extending to the submucosa, and 80% to 90% beyond the submucosa.^[12] In our case, the decision was taken to perform an extended lymph node dissection (D2). Retrospective studies from Japan, involving 10,000 patients, support that extended lymph node dissection combined with gastrectomy prolongs survival compared to limited lymph node dissection (D1), and also D2 dissection helps in staging cancer more accurately.^{[13],[14],[15]}

There are many controversies regarding the best reconstruction methods after total gastrectomy. The Roux-en-Y esophagojejunostomy is a simple option for reconstruction. Recent advances include jejunal pouch reconstruction. The study conducted by Chen et al. in a teaching hospital in China revealed a better quality of life, lower incidence of dumping syndrome, and better nutritional and evaluation status.^[6]

Conclusion

Gastric carcinoma is cancer in the fifth to seventh decades with male preponderance. The report highlights the importance of suspecting gastric carcinoma in an elderly male even with trivial symptoms. Early detection helps in linked with better prognosis and the treatment modality ranges from endoscopic resection of tumor to total gastrectomy. An expertise decision is required in assessing the treatment modality suitable to the patient. Here, in this case, jejunal pouch reconstruction was performed for a better postoperative quality of life.

Informed consent

Taken from the patient.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Acknowledgment

Our sincere thanks to Squad Medicine and Research for their support and guidance.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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