India has a low incidence of gastric cancer. It ranks among the top five most common cancers. Regional diversity of incidence is of importance. It is the second most common cause of cancer related deaths among Indian men and women in the age between 15 and 44. Helicobacter pylori carcinogenesis is low in India. Advanced stage at presentation is a cause of concern. Basic and clinical research in India reveals a globally comparable standard of care and outcome. The large population, sociodemographic profile and challenges in health expenditure, however, remain a major challenge for health care policy managers. The newer formation of National Cancer Grid, integration of national databases and the creation of social identification database Aadhaar by The Unique Identification Authority of India are set to enhance the health care provision and optimal outcome.
We present a case of spontaneous retrograde migration of mid ureteric calculus into the kidney. A 55 year old male, who presented with left flank pain, was diagnosed with a left mid ureteric calculus on ultrasound abdomen. X ray KUB and CT KUB confirmed the same. Intervention was planned as he did not respond to Medical Expulsive Therapy. On day three, he developed urinary intermittency followed by pain relief. We suspected the calculus to have spontaneously passed out and an X ray KUB was done to confirm it. To our surprise, the same calculus was seen in the kidney instead of ureter. A repeat CT KUB confirmed that the calculus has up migrated into the lower calyx of the kidney.
Background
Stomach is the best conduit available after esophageal resection for both benign and malignant esophageal disorders. Malignancy in the gastric conduit after esophageal resection is a rare occurrence with worst outcome.
Methods
13 cases of gastric conduit malignancy admitted in our institution from 2006 to 2016 were analysed. Malignancy in the conduit may be a second primary or a recurrence of the tumor bed or at anastamotic site. Indication for surgery, Demographic profile, Interval between occurrence and primary disease, site, type, stage and grade of malignancy, route of the conduit (retro sternal/posterior mediastinum), presence of pyloroplasty, post operative therapy and complications were analysed.
Results
The mean interval between primary esophageal malignancy and conduit cancer was 4.3 years. 6 cases represented the second primary, 4 represented anastamotic recurrence and 3 cases of bed recurrence. All cases were adenocarcinoma. Out of 13 patients 8 were advanced malignancy. Out this 8, one patient had conduit pulmonary fistula. Only feeding/stenting procedure and chemo/RT were done. In the remaining 5 patients wedge resection in 1patient and total conduit gastrectomy in 4 patients with colonic replacement were done. Comparing 2 cases of substernal with 2 cases of posterior mediastinal colonic conduit placement the post operative pulmonary complications are less and no need for delay in RT in substernal route. Median overall survival in non surgical patients was 6.2 months (range 4–11 months) and 1.9 months (range 6months -5.6 years) in surgical patients.(P = 0.003)
Conclusion
Colonic reconstruction and even partial resection is possible in the management of conduit malignancy after esophagectomy and even yields survival closer to primary gastric maligmancy. Placement of the conduit in the substernal route offers some advantage in treating the tumour bed with radiotherapy. Continuous postoperative monitoring after esophagectomy with the monotored surveillance program is needed to select appropriate cases for better results.
Disclosure
All authors have declared no conflicts of interest.
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