Transverse colon stenosis following laparoscopic total gastrectomy for gastric remnant carcinoma.

Laparoscopic surgery for remnant gastric cancer has been reported in a limited number of cases, and data on post-operative complications are lacking. A 58-year-old male was admitted with remnant gastric cancer. He had undergone open subtotal gastrectomy 9 years ago for gastric cancer. Laparoscopic total gastrectomy was performed, and he was discharged on the 10th day uneventfully. The patient had complained of nausea and vomiting in the 2nd post-operative month. He clinically and radiologically diagnosed as ileus and required open emergency surgery. There was a transverse colon stenosis near the splenic flexure. Hartmann's procedure was done, and he was discharged on day 17. We have limited knowledge about colonic complications after laparoscopic gastric surgery. The development of stenosis in the transverse colon is one of these complications that should be kept in mind. As far as we know, such a complication has never been reported before.

INTRODUCTION

Gastric cancer is a common cancer type in the world, especially in Eastern societies, and the basis of treatment is surgical resection. Increased screening frequency in gastric cancer has allowed the diagnosis to be made in the early stages of the disease, leading to successful surgical and medical treatment options. Remnant stomach cancer is seen in cases of previously done subtotal gastrectomy and/or gastroenterostomy for malign or benign causes. The practice of minimally invasive surgical techniques in gastric cancer is increasing day by day. Increased laparoscopic applications and experience provide the opportunity for laparoscopy in advanced stage and remnant stomach cancer.[1] Information on complications after laparoscopic surgery in remnant stomach cancer is limited.[1] In this study, we aimed to present a case of colon stenosis after laparoscopic remnant gastrectomy.

CASE REPORT

A 58-year-old male patient was admitted to our clinic with the diagnosis of remnant gastric cancer. Nine years ago, the patient underwent open subtotal gastrectomy and Billroth II reconstructive surgery due to stomach cancer. A biopsy of a suspected ulcerous lesion of the remnant stomach was made in the esophagogastroscopy for the evaluation of the patient who had radiotherapy and chemotherapy story after surgery. Laparoscopic complementary gastrectomy was planned in the patient whose biopsy pathology result was poorly cohesive carcinoma. The patient in the ASA-3 class with a history of diabetes mellitus and oral antidiabetic use was operated on. Pneumoperitoneum was formed with Veress needle from the left upper quadrant in the patient with a median incision on the upper abdomen. The 10-mm working trocars were placed under the umbilicus, the lower right quadrant and the lower left quadrant; the 5-mm working trocar was placed in the upper right quadrant. Because the liver was sticking to the diaphragm, the liver retractor was not used. Adhesions to the anterior abdominal wall were removed. The intestinal loop of antecolic Billroth II gastroenterostomy anastomosis was cut and sealed with linear staples. The greater curvature was released along with the remaining omentum. Lesser curvature lymph nodes were dissected and included in specimen. The oesophagus was cut and closed with a linear stapler. Subsequently, antecolic oesophagojejunostomy was performed intracorporeally with single layer 3/0 prolene. The jejunojejunostomy with linear stapler was performed between the place that was 100 cm distal after oesophagojejunostomy anastomosis and the loop that was 15 cm away from the ligament of Treitz. The specimen was removed by suprapubic route. The operation time was 390 min with bleeding 100 cc. The patient was discharged without any problems on the 10th day. The pathology was reported as a 3 cm × 1.5 cm poorly cohesive carcinoma type (signet ring cell form) lesion with a proximal margin of 2 cm and a distal margin of 7 cm. Proximal distal and radial surgical margin was reported as negative. There was extensive lymphovascular invasion. In total, 25 lymph nodes were removed from the patient, and 11 of these lymph nodes were positive. The medical oncology clinic initiated chemotherapy treatment for the patient. Chemotherapy was continued, and the patient was admitted to the emergency department due to the complaints of abdominal pain, nausea and vomiting in the 2nd post-operative month. Subsequently, computed tomography showed dilated terminal ileum, ascending colon, transverse colon and air–fluid levels. Diameter increase of 7 cm at its widest point in transvers colon was seen [Figure 1]. Laparotomy was performed due to the diagnosis of ileus. At the level of the splenic flexure at the colon, there was severe stenosis. The transverse colon near the splenic flexure narrowed in the shape of beak. There was no adhesion or abscess. When splenic flexure was mobilised, an iatrogenic colostomy occurred distal to the stenosis. The transverse colon was transected just before the colon stenosis, and the end colostomy was fashioned. The patient was discharged on the 17th post-operative day after discontinuation of abdominal drainage on conservative follow-up. The chemotherapy of the patient with good general condition is continuing during the 2-month follow-up.

Figure 1

The area of stenosis in the transverse colon is marked with an arrow

DISCUSSION

The incidence of gastric remnant carcinoma was 1.9% in those who had previous gastric surgery.[2] Studies comparing open and laparoscopic remnant stomach cancer surgeries have found similar oncologic outcomes, while laparoscopic surgical procedures have advantages regarding early oral intake and short hospitalisation.[3] However, the past surgery-related adhesions cause more prolongation of operation in laparoscopic surgery in remnant gastric cancer.[1] In Young et al.'s study, intraperitoneal adhesions were found more in the patients who had been operated for malignant gastric pathologies than benign reasons. It was emphasised that laparoscopy is more suitable in benign pathologies; however, the difference was not statistically significant.[4]

Previous surgery can cause difficulty in recognising anatomical structures and consequently increase in complications. The post-operative complication rate in remnant stomach cancer is reported to be 6.5%–20%.[1] Colon-related complications after laparoscopic stomach tumour surgery are rarely seen. Lee et al. compared laparoscopic gastric cancer surgery with open laparoscopic gastric cancer surgery, although colocutaneous fistula was reported in a case of laparoscopic surgery group and similar complications could develop in both techniques.[5] Ryu et al. reported two colon-related complications in their study of laparoscopic gastrectomy. In one case, colectomy was performed with intraoperative open surgical conversion due to intraoperative middle-colic artery injury-induced ischaemia. In another patient, a colon fistula was encountered postoperatively.[6] Transverse colon stenosis after gastrectomy is a rarely reported complication. As a general principle, it is accepted that bridge ileus cannot develop in the colon. Post-operative late colonic obstruction may occur with ischaemic stenosis. No such complication has been reported after laparoscopic surgery. In 1968, a unique case report was reported following an open surgery.[7]

CONCLUSION

We have limited knowledge of the complications that may develop in the post-laparoscopic gastric cancer surgery. We believe that this case will contribute to the knowledge of laparoscopic surgery with transverse colon stenosis after laparoscopic gastrectomy for remnant gastric cancer.

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.