A case of esophageal cancer with mesojejunal lymph node metastasis after total gastrectomy.
ABSTRACT A 56-year-old man was diagnosed with esophageal cancer by upper gastrointestinal endoscopy for examination of dysphagia. The patient had undergone total gastrectomy and jejunal interposition 4 years previously for a gastric cancer at the pT1N0M0 stage according to the UICC-TNM classification. Enhanced CT findings revealed a 3-cm-diameter mass located near the superior mesenteric artery. We conducted subtotal esophagectomy associated with partial jejunectomy including mesojejunectomy. The mass was histologically diagnosed to be mesojejunal lymph node metastasis from esophageal cancer. Mesojejunal lymph node metastasis from esophageal cancer developing after total gastrectomy has been reported in only three cases including ours. The present lymph node metastases may have occurred via the newly developed lymphatic drainage route through the esophagojejunostomy, and this metastatic lymph node can be considered the regional lymph node. Therefore, resection of the interposed jejunal limb with mesojejunectomy may be rational in surgery on esophageal cancer developing after total gastrectomy.
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ABSTRACT: We report on a case of thoracic esophageal cancer following total gastrectomy (rho-Roux-en-Y reconstruction) with metastasis to the mesojejunal lymph nodes. Subtotal esophagectomy with reconstruction using pedicled colon and dissection of two lymph node fields was performed. During the operation, we found three lymph nodes showing metastasis at the rho-Roux loop of the mesentery, and resected the rho-Roux loop. The route of the lymphatic drainage to the abdomen from the thoracic tumor seemed to have been changed by the prior gastrectomy. Based on the pathological findings, the case was diagnosed with T2N4M0, Stage IVa. We did not confirm that the distant metastases skipped the mesojejunal lymph nodes preoperatively; the distant metastases were detected accidentally by lymphoscintigraphy using technetium-99m tin colloid. We believe this case highlights the need for detailed examinations in esophageal cancer patients who have had prior gastrectomy.The Japanese Journal of Thoracic and Cardiovascular Surgery 12/2004; 52(11):542-4.
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ABSTRACT: Metastatic pattern of lymph node (LN) and surgery options for gastric stump cancer (GSC) remain controversial. The aim of this study was to investigate LN metastasis and lymphadenectomy for GSC for curative purposes. Sixty-seven patients with GSC were analyzed retrospectively. The metastatic rates of LN were as follows: 63.3% in right cardia (No. 1), 33.3% in left cardia (No. 2), 75.0% in lesser curvature (No. 3), 53.3% in greater curvature (No. 4), 40.0% in celiac artery (No. 9), 60.0% in splenic hilus (No. 10), 72.7% in splenic artery (No. 11), 36.1% in hepatoduodenal ligament (No. 12), 8.3% in retropancreatic (No. 13), 21.4% in para-aortic (No. 16), 50% in supra-diaphragm (No. 111), 16.7% in LN within jejunal mesentery, respectively. All nine patients who only received simple laparotomy died within 1 year. The overall 5-year survival rate of GSC was 17.9% (12/67), including 100% for stage I, 80.0% for stage II, 12.1% for stage III, and 0% for stage IV. Moreover, the 5-year survival rate (36.7%, 11/30) for curative patients was significantly better than that (3.6%, 1/28) of non-curative patients (chi(2) = 7.76, P < 0.01). Our results imply that GSC has a wide range of LN metastases, including LN within jejunal mesentery in B-II reconstruction cases, and curable resection may obtain better results. Therefore, we suggest that radical operation for B-I patients needs removal of gastroduodenectomy anastomosis and the above LNs, and that B-II patients need removal of 10 cm of jejunum besides gastrojejunostomy anastomosis, and clearance of LN within its mesentery, in addition to B-I GSC.Journal of Surgical Oncology 04/2003; 82(4):241-6. · 2.64 Impact Factor
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ABSTRACT: Lymphatic flow and the incidence of lymph node metastasis in remnant stomach cancer after distal gastrectomy are obscure. There is consequent controversy about appropriate lymph node dissection in such cases. Thirty-three consecutive patients with remnant stomach cancer and 44 consecutive patients primary gastric cancer in the upper third of the stomach were investigated retrospectively about lymphatic flow by injection of activated carbon particles, and about the incidence of lymph node metastasis. Lymphatic flow and the incidence of lymph node metastasis in remnant stomach cancer after distal gastrectomy without lymph node dissection were the same as those in primary gastric cancer in the upper third of the stomach. Lymphatic flow after distal gastrectomy with lymph node dissection frequently streamed toward the para-aortic lymph nodes through the lymph nodes along the greater curvature and the suprapancreatic lymph nodes. Lymphatic flow toward the jejunal and colonic mesentery was observed regardless of the method of reconstruction. This lymphogenesis was clearly observed, especially in patients with tumors invading the anastomosis site of Billroth-II reconstruction. Station Nos. 110 (lower paraesophageal) and 111 (supradiaphragmatic) lymph nodes were also stained, despite being considered sites of distant metastasis irrespective of the method of reconstruction. On the basis of the evidence of altered lymphatic flow and the incidence of lymph node metastases in remnant stomach cancer, left upper abdominal evisceration with para-aortic lymph node dissection should be performed in advanced remnant stomach cancer.Hepato-gastroenterology 49(44):580-4. · 0.77 Impact Factor
A case of esophageal cancer with mesojejunal lymph node
metastasis after total gastrectomy
Ayu Kato•Ken-ichi Mafune•Junko Kuroda•
Keisuke Kubota•Masashi Yoshida•
Keiichiro Ohta•Masaki Kitajima
Received: 14 May 2010/Accepted: 1 November 2011/Published online: 20 November 2011
? The Author(s) 2011. This article is published with open access at Springerlink.com
ageal cancer by upper gastrointestinal endoscopy for
examination of dysphagia. The patient had undergone total
gastrectomy and jejunal interposition 4 years previously for
a gastric cancer at the pT1N0M0 stage according to the
UICC-TNM classification. Enhanced CT findings revealed
a 3-cm-diameter mass located near the superior mesenteric
artery. We conducted subtotal esophagectomy associated
with partial jejunectomy including mesojejunectomy. The
mass was histologically diagnosed to be mesojejunal lymph
node metastasis from esophageal cancer. Mesojejunal
lymph node metastasis from esophageal cancer developing
after total gastrectomy has been reported in only three cases
including ours. The present lymph node metastases may
have occurred via the newly developed lymphatic drainage
route through the esophagojejunostomy, and this metastatic
lymph node can be considered the regional lymph node.
Therefore, resection of the interposed jejunal limb with
mesojejunectomy may be rational in surgery on esophageal
cancer developing after total gastrectomy.
A 56-year-old man was diagnosed with esoph-
Mesojejunal lymph node ? Total gastrectomy
The number of patients developing esophageal cancer after
gastrectomy has increased. However, the route of lymphatic
drainage and the pattern of lymph node metastasis are
unknown. In a remnant gastric cancer, patients with lymph
node metastasis to the mesojejunum used for reconstruction
are frequently reported. However, only a few cases of
esophageal cancer after gastrectomy. The optimal extent of
lymphadenectomy is controvertial. Herein, we report a case
of esophageal cancer with mesojejunal lymph node metas-
tasis following total gastrectomy with jejunal interposition.
A 56-year-old man consulted his primary physician for
dysphasia. He had undergone total gastrectomy with lymph
node dissection 4 years previously for gastric cancer, which
had been pathologically diagnosed as pT1N0M0, stage IA
(n = 0/45), according to the 6th edition of the UICC-TNM
classification . The reconstruction was jejunal interposi-
tion via the retro-colic route. He underwent upper gastro-
intestinal endoscopy and was referred to our hospital for an
esophageal ulcerative lesion. Barium esophagography
revealed a 5-cm, type 2 ulcerative lesion in the lower tho-
racic esophagus (Fig. 1). Upper gastrointestinal endoscopy
showed a tumor occupied one third of the circumference of
the esophagus. Pathological examination of the biopsy
specimen revealed poorly differentiated squamous cell
revealed a 3-cm mass with a central low density area near
the superior mesenteric artery (SMA) (Fig. 2).
Consequently, we diagnosed the tumor as a stage
cT3N1M1b esophageal cancer according to the 6th edition
of the UICC-TNM classification and performed subtotal
esophagectomy with lymph node dissection and partial
A. Kato (&) ? K. Mafune ? J. Kuroda ? K. Kubota ?
M. Yoshida ? K. Ohta ? M. Kitajima
Department of Surgery and Center for Digestive Diseases,
International University of Health and Welfare Mita Hospital,
1-4-3 Mita, Minato-ku, Tokyo 108-8329, Japan
Esophagus (2011) 8:311–314
hemi-colon was used for esophageal reconstruction. The
mass shown in the abdominal CT was a swollen lymph
node located around the second branches of the second
jejunal artery used for jejunal interposition. No swollen
lymph node was observed along the marginal artery of the
jejunum. Therefore, the 25-cm-long jejunum used for
interposition was resected with the second branches of the
second jejunal artery. The anal side of the right hemi-colon
and the remaining jejunum interposition were anastomosed
(Figs. 3, 4).
Histologically, the tumor was diagnosed as poorly dif-
ferentiated squamous cell carcinoma, and metastasis was
found in the subcarinal lymph node and the mesojejunal
lymph node. The pathological stage was pT3N1 (2/37)M1b,
stage IVB, according to the 6th edition of the UICC-TNM
Classification of Malignant Tumors. Two courses of FP
10 mg/body/day, day 1) were administered as adjuvant
chemotherapy, and then S-1 therapy (120 mg/body/day,
4 weeks administration and 2 weeks withdrawal) was per-
formed for 2 years. No recurrence was observed for 5 years
after the operation.
days 1–5 ? CDDP
The incidence of esophageal cancer after gastrectomy is
2.8–10% and has increased [2–4]. In an esophageal cancer
after gastrectomy, abdominal lymphatic drainage routes are
modified, but they are unknown.
In a remnant stomach cancer, metastasis to the mesojej-
unal lymph node is frequently observed. Especially in cases
of Billroth II reconstruction with tumor invasion into the
jejunum, the incidence of mesojejunal lymph node metas-
tasis increased (9.1–55%) [5–7]. Therefore, the Japanese
Classification of Gastric Carcinoma prescribes describing
whether invasion of a remnant stomach cancer into the
Fig. 1 Esophagography. Esophagography shows a type 2 tumor,
5 cm in length, in the lower thoracic esophagus
Fig. 2 Abdominal computed tomography (CT). Enhanced CT shows
a tumor with central necrosis, 3 cm in diameter, near the superior
Fig. 3 Surgical specimen. A type 2 tumor is located in the lower
thoracic esophagus. A swollen lymph node is observed along the
second branch of the jejunal artery
312 Esophagus (2011) 8:311–314
jejunum is observed or not . In this case, mesojejunal
lymph node metastasis occurred although invasion of the
jejunum was not detected. Also, the metastatic lymph node
was not at the marginal region of the jejunal interposition,
but around the second branches of the jejunal artery.
Actually, in a remnant stomach cancer, lymphatic drain-
age into the jejunum and the colon was more frequently
observed compared to a primary gastric cancer. In addition,
incidence of lymph node metastasis . Aiko et al. 
reported six patients with abdominal lymph node metastasis
around the remnant stomach or around the celiac artery
among 20 cases of esophageal cancer after gastrectomy. In
esophageal cancers after gastrectomy, only three cases with
mesojejunal lymph node metastasis including the present
case have been reported, and all the patients underwent total
en-Y type in the other two cases.
In a remnant stomach cancer, lymphatic connection
between the stomach and the jejunum is established through
the anastomosis after the operation. Moreover, lymphatic
connection with adjacent organs is established through the
adhesion . It is supposed that new lymphatic drainage
the anastomosis after total gastrectomy.
In an esophageal cancer, we can usually observe the
lymphatic drainage routes between the lower esophagus
and the abdominal aortic lesion. One is along the left
gastric artery, and the other is along the left inferior phrenic
artery. The lymph duct along the left inferior phrenic artery
flows into the aortic lesion directly.
In the present case, we separated at the second branch of
the jejunal artery and preserved the anal side of the jejunal
interposition because the jejunum used for reconstruction
in the previous operation was long enough. Should we
remove all the jejunal interposition? How long should
the jejunum resection be if the previous operation was a
Roux-en-Y reconstruction? And should we perform lymph
node dissection around the SMA? These many problems
are still under consideration. In an advanced remnant
stomach cancer, adequate resection of the jejunum and
lymph nodes, especially lymph node dissection around the
SMA, is important [7, 11]. Some patients with a remnant
stomach cancer showed a long survival after optimal lymph
node dissection [5, 12, 13]. Also in an esophageal cancer
after total gastrectomy, the mesojejunal lymph nodes may
be regional lymph nodes, and therefore resection of the
interposed jejunum used for reconstruction with mesoje-
junectomy will be required.
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mits any noncommercial use, distribution, and reproduction in any
medium, provided the original author(s) and source are credited.
This article is distributed under the terms of the
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