PMC5459570_01
Endoscopic examination shows a slightly elevated-type and flat-type tumor in the middle thoracic esophagus (A) and an ulcerative-type tumor in the cardia of the stomach (B). Contrast-enhanced abdominal computed tomography reveals swelling of the lesser curvature lymph node, which invades the stomach, the body and tail of the pancreas and the left gastric artery, splenic artery and celiac artery (C, D).
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Endoscopic examination showed a slightly elevated-type and flat-type tumor about 60 mm in diameter in the middle thoracic esophagus (Fig. 1A) and an ulcerative-type tumor about 35 mm in diameter in the cardia of the stomach (Fig. 1B). Computed tomography revealed swelling of the lesser curvature lymph node, and it involved the stomach, the body and tail of the pancreas and the left gastric artery (LGA), splenic artery (SpA) and celiac artery (CA) (Fig. 1C, D).
Preoperative angiography. Conversion of hepatic blood flow by coil embolization of the common hepatic artery (A). On day 7 after embolization, urgent hemostasis via interventional radiology was performed (C) due to major bleeding(arrow) from the LGA (B).
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The Appleby operation was proposed to the patient as curative lymphadenectomy after conversion of blood flow by coil embolization of common hepatic artery (CHA) (Fig. 2A). On day 7 after embolization, urgent hemostasis via interventional radiology was performed due to major bleeding from the LGA (Fig. 2B, C), followed by surgery.
Intraoperative findings. Taping of the common hepatic artery, proper hepatic artery and gastroduodenal artery (A). Cutting of the celiac artery (B). Removal of the embolization coil and cutting of the common hepatic artery (C). Condition after total gastrectomy, distal pancreatectomy, splenectomy, cholecystectomy, and D2 lymph node dissection (D).
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Total gastrectomy, distal pancreatectomy, splenectomy, cholecystectomy and D2 lymph node dissection were performed by the Appleby procedure (Fig. 3), followed by reconstruction using the jejunum (Roux-en-Y method).
Macroscopic findings. The resected specimen shows a mass of 63 x 46 mm in diameter on the gastric cardia (A) that infiltrates the pancreas, splenic artery and left gastric artery (B).
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The resected specimen showed a mass 63 x 46 mm in diameter on the serosal surface of the gastric cardia involving the pancreas, SpA and LGA (Fig. 4).
Endoscopic examination at 38 months after surgery reveals recurrence (arrows) of the primary lesion in the middle thoracic esophagus (A, B). Photodynamic therapy using talaporfin sodium and a diode laser was performed (C). A complete response was obtained for the lesion (arrows) (D).
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Endoscopic examination and biopsy at 38 months after surgery revealed recurrence of the primary lesion in the middle thoracic esophagus (Fig. 5A, B). Because the patient refused another highly invasive procedure, i.e., salvage endoscopic submucosal dissection and salvage esophagectomy, minimally invasive PDT using talaporfin sodium and a diode laser was attempted (Fig. 5C). Complete response was obtained for the primary lesion (Fig. 5D), and the patient is alive at 50 months after the salvage Appleby operation.