Gastric remnant carcinoma.

Over 1200 cases of carcinoma of the gastric remnant have been reported in the literature. There is an increase of this type of carcinoma in postoperative stomachs with atrophic gastritis and intestinal metaplasia. The cause and effect relationships remain to be fully elucidated. In patients with late postgastrectomy symptoms, carcinoma of the gastric remnant should be considered in the differential diagnosis. In a study of 350 asymptomatic patients who were more than 20 years from Billroth II gastric resection, 14 carcinomas were discovered in the region of the stoma. Preoperatively, gross endoscopic appearance and multiple biopsies will usually provide the diagnosis. At the time of revisional surgery, frozen section of gastric biopsies or the resected specimen may be necessary to exclude the diagnosis. At present there is widespread interest in several procedures in the treatment of benign ulcer disease. In selected patients, proximal gastric vagotomy is receiving particular interest. It remains to be determined what, if any, gastric mucosal alterations occur. Since the pyloric mechanism is intact, no stoma is created and no portion of the stomach resected; long-term followup of these patients will be of interest. Information as to the cause of gastric remnant carcinoma can be forthcoming only by evaluation of all groups of patients requiring gastric surgery for benign disease. At the same time, further investigation of patients with gastric carcinoma without prior resection who have atrophic gastritis and intestinal metaplasia is also necessary. The histologic type of carcinoma that develops in the gastric remnant is usually more favorable for surgical cure than those seen in the intact stomach. This means that early diagnosis by radiologic and endoscopic study of postgastrectomy patients developing symptoms is highly desirable. Because of the long interval between gastrectomy and gastric remnant carcinoma these patients are often in the older age group. The location of the lesion in the remaining proximal stomach will nearly always require total gastrectomy. This plus the age factor means that the operative mortality will be rather high. We are unable to explain why in 22 years of observing postgastrectomy patients we have seen only one case of gastric remnant carcinoma. This patient was successfully treated by left transpleural transdiaphragmatic total gastrectomy with Roux-en-Y esophagojejunostomy. This method is particulary easy in the patient who has has an antecolic Billroth II gastrectomy. If the jejunum cannot be adequately mobilized through a radial incision extending laterally from the esophageal hiatus, we use a peripheral diaphragmatic incision in circumferential fashion. This gives excellent exposure of the upper abdominal contents and also preserves the phrenic nerve. As a result, ventilatory function of the left leaf of the diaphragm is preserved postoperatively.