A Caliber Persistent Artery (Dieulafoy’s Lesion) which is Associated with an Early-Stage Gastric Stump Cancer Following a Distal Gastrectomy

Abstract

A 75-years old man was hospitalized with symptoms which suggested gastric cancer. Thirty-eight years ago, he had undergone a Billroth-II gastric reconstruction for a peptic ulcer. At the present admission, he had presented with an eight-month history of recurrent haematemesis, epigastric pain, vomiting, and fatigue. The emergent endoscopy showed a type 0-IIc (superficial depressed) early gastric stump cancer in the anastomotic area and total removal of the gastric remnant and the jejunal segment was performed. The histological examination of the surgical specimen showed a gastric adenocarcinoma that invaded the mucosa and the submucosa, without lymph node metastases (pT1bN0 stage). Besides the tumour, enlarged vessels were observed in the submucosa and the muscularis propria, some of which were thrombotic. The surrounding normal gastric wall also presented submucosal oversized vascular spaces, some of which were protruding through the muscularis mucosae in the mucosal layer. Based on these characteristics and the recurrent haematemesis, a final diagnosis of early gastric stump carcinoma which was associated with Dieulafoy's lesion was made. This association has not yet been reported in the literature and it allowed us to diagnose the gastric stump cancer in a very early stage.

Aberrant metastatic behavior and particular features of early gastric cancer

“…Gastric stump carcinoma is defined as a GC occurring after partial gastrectomy for benign disease or cancer, and affects 1–3% of the patients . It occurs earlier in patients that underwent gastrectomy for a malignant tumor than for a benign disease (≤10 vs >20 years).…”

“…This difference is probably based on a predisposing malignant status of the surrounding mucosa. Tumor location depends on the type of surgery (non‐stump area for Billroth I (46–51%) and carcinoma in the anastomotic area, after the Billroth II (38–60%) . It is also considered that the risk for GC is higher after the Billroth II than the Billroth I procedure as a result of continuous stump washing by the reflux of bile, pancreatic, and intestinal juices, and the occurrence of chronic atrophic gastritis in 93% of the patients .…”

“…It is also considered that the risk for GC is higher after the Billroth II than the Billroth I procedure as a result of continuous stump washing by the reflux of bile, pancreatic, and intestinal juices, and the occurrence of chronic atrophic gastritis in 93% of the patients . Post‐Billroth II carcinomas occur at a longer time interval than post‐Billroth I carcinomas (30–32 vs 12–21 years) .…”

Mass-like Dieulafoy’s lesion associated with advanced gastric cancer at the antrum of stomach: a case report and literature review

“…Only 18 cases of stomach DL were ever reported to coexist with gastric cancer, and only 2 of the 18 cases were advanced gastric cancers (Table 1) [1–7]. Although there is no definite pathophysiologic explanation regarding the association between DL and gastric cancer, discrete uniform pathologic descriptions have been reported in all cases - the location of DL constantly corresponded to the location of the gastric cancer [5, 8]. To the best of our knowledge, no single English report describes a mass-like DL associated with advanced gastric carcinoma in the antrum.…”

“…PostUnknownIIcOn DieulafoysigsmBenignKishikawa, 2003 [3]1569/MC. Post50 × 40IIaOn Dieulafoytub1smBenignTaketsuka, 2006 [4]1675/MStump4 × 3IIcOn Dieulafoytub1sm0-IIcGurzu, 2013 [5]Advanced Gastric Cancer148/MM.Ant20 × 20IIcOn DieulafoysigmpBenignTaniguchi, 1992256/MC. Less50 × 25IIc + IIaOn Dieulafoytub2mpBenignKishimoto, 2005 [6]3†57/FA.…”