Intestinal-type gastric adenocarcinoma in a reconstructed gastric tube, after transhiatal esophagectomy

Esophageal cancer is the ninth cause of neoplasias and the sixth cause of cancer mortality. Surgical treatment of those tumors with gastric or colonic replacement has advanced significantly, but has been a risk factor for the development of metachronous cancer in reconstructed gastric tubes. Treatment based on total gastrectomy with colon ascension is an efficacious therapeutic option, but there is a high risk for severe complications. A 34-year-old woman had a past medical history of distal esophageal peptic stricture that was refractory to treatment with esophageal dilations, as well as ulcerated acute esophagitis and Barrett’s esophagus with high-grade dysplasia. In 2006, she underwent transhiatal esophagectomy with gastric pull-up with no complications and the definitive histopathologic study reported extensively ulcerated acute and chronic esophagitis, Barrett’s esophagus, and complete intestinal metaplasia of the gastric mucosa. Numerous control endoscopies were carried out over a 2year period, after which the patient did not continue with the follow-up sessions. The patient sought medical attention again at our hospital center for illness that began in January 2016 with asthenia, adynamia, and melena. A computed tomography scan showed thickening of the mucosa of the intrathoracic gastric chamber (fig. 1) and panendoscopy revealed severe esophagitis, partial stricture of the gastroesophageal junction, and a tumor that extended from the greater curvature to the antrum, with friable and indurated mucosa. The histopathologic study from the biopsy reported diffuse, moderately differentiated gastric adenocarcinoma with the presence of signet ring cells. Therapeutic surgery consisting of right transthoracic gastrectomy with retrosternal colon ascension was proposed. Employing a cervical, right anterolateral and supraumbilical transthoracic approach, total gastrectomy was performed with dissection of the ascending colon, cecum, and 4 cm of the ileum. The middle colic artery and its branches were spared and hand-sewn end-to-end ileotransverse anastomosis was carried out. There were no complications during the surgery and the definitive histopathologic study reported intestinal-type gastric adenocarcinoma with lymphovascular invasion reaching the subserosa: AJCC clinical stage IIA (pT3N0M0) (fig. 2). At present, the patient is tolerating an oral diet and receiving adjuvant chemotherapy.