P1.151. Management of Antral Adenocarcinoma 14 Years After Esophagectomy With Gastric Pull-Up: A Surgical Challenge

Abstract

Esophageal Cancer: Other An 84-year-old male had previously undergone a three-field esophagectomy with gastric pull-up reconstruction for stage I adenocarcinoma of the distal esophagus 14 years earlier. He remained disease-free during long-term follow-up. He subsequently presented with progressive dysphagia and mild, unintentional weight loss. Upper gastrointestinal endoscopy and endoscopic ultrasound demonstrated a stage II adenocarcinoma of the gastric antrum arising within the gastric conduit. Positron emission tomography–computed tomography demonstrated no evidence of metastatic disease. Comprehensive geriatric assessment was performed and confirmed that the patient was functionally independent, with preserved physiological reserve and no major contraindications to oncologic treatment or surgical intervention. His case was discussed at a multidisciplinary team meeting. The patient’s goals of care and treatment preferences were carefully explored, and upfront surgical management with curative intent was recommended. Several surgical strategies were considered. These included total gastrectomy of the gastric conduit with reconstruction using colon transposition or small-bowel supercharged reconstruction, as well as a more limited resection in the form of antrectomy. While total gastrectomy would have ensured maximal oncologic clearance, it may be associated with significant operative complexity and potential morbidity, particularly in the context of advanced age and prior extensive upper gastrointestinal surgery. After careful consideration of oncologic feasibility, technical factors, and patient-specific risk, a limited antrectomy with preservation of the right gastroepiploic artery was selected in order to maintain conduit vascularity and minimize surgical trauma. Surgery was performed successfully, with meticulous preservation of the right gastroepiploic artery supplying the gastric conduit. Adequate oncologic resection margins were achieved. The postoperative course was uneventful, with no surgical or medical complications, and the patient recovered well. Learning point: Secondary gastric malignancy within a gastric pull-up conduit is a rare but clinically significant late complication following esophagectomy. Management requires individualized decision-making, balancing oncologic principles with patient factors and complex reconstructive considerations. In selected patients, limited resection with preservation of conduit blood supply can provide a safe and effective surgical option, emphasizing the importance of multidisciplinary evaluation and tailored surgical strategy.