Abstract
Background
One-stage surgery for synchronous esophageal and pancreatic cancer has only very rarely been reported, mostly in younger patients. This is to our knowledge the first case of a completed multi-modality treatment (induction chemo-radiation, one-stage surgery and adjuvant chemotherapy) in an elderly patient.
Methods
Difficult case report.
Results
A 77 years old ASA-2 male patient, with a symptomatic 4 cm long adenocarcinoma of the gastro-esophageal junction, ycT3N0M0 and an adenocarcinoma of the ampulla of Vater (cT2N0M0, discovered by chance) underwent surgery after induction chemo-radiation (CROSS scheme). The patient previously had undergone a sigmoidectomy for perforated diverticulitis by median laparotomy. A one-stage radical subtotal esophagectomy was performed combined with a duodeno-pancreatectomy (Whipple) by laparotomy and right thoracotomy. The radical resection of the esophagus and pancreatic head with 2-field lymphadenectomy and total gastrectomy (due to resection of the gastro-duodenal artery) was done with intestinal reconstruction using a long segment right coloplasty with esophago-colic anastomosis in the right chest apex. Operative time was 710 minutes and blood loss 700 ml. Post-operative course was complicated by a small perforation of the proximal jejunum requiring reoperation for over-sewing at day 10 (Dindo-Clavien grade IIIA). Thereafter uneventfull recovery and post-operative hospital stay was 34 days until discharge to patient's home. Pathology: GEJ Adenocarcinoma ypT3N0M0, G2, R0 and adenocarcinoma of the ampulla of Vater with duodenal and peri-pancreatic fat invasion pT4N1M0, G2, R0. 2 lymph nodes were involved on the pancreatic specimen out of total 62 nodes (esophagectomy 40, duodeno-pancreatectomy 22). Adjuvant chemotherapy was administered for the locally advanced pancreatic cancer. Nocturnal nutritional supplements by jejunostomy were pursued during chemotherapy and the feeding jejunostomy was removed after full functional recovery 4 months postoperatively. Pancreatic enzyme supplementation was pursued. The patient has recovered his normal nutritional habits at 3 months and all preoperative physical activities at 6 months. 6 months follow-up CT-scan showed no recurrence.
Follow-up CT-scan after 1 year is suspicious for a solitary liver metastasis currently under investigation.
Conclusion
Combined multi-modality treatment for esophageal and pancreatic treatment is feasible in otherwhise fit elderly patients (> 75 years) with an acceptable functional and metabolic outcome.
Disclosure
All authors have declared no conflicts of interest.
Combined three-part humeral anterior fracture-dislocation and humeral shaft fracture treated with one-stage long stem shoulder hemiarthroplasty in an active elderly patient