Asian Cardiovasc Thorac Ann 2001;9:218-220
© 2001 Asia Publishing EXchange Pte Ltd
Gastric Cancer Found Incidentally During Gastroepiploic Artery Harvest
Hitoshi Hirose, MD,
Atsushi Amano, MD1,
Akihito Takahashi, MD,
Naoko Nagano, MD1
Department of Cardiovascular Surgery Kobari General Hospital Chiba, Japan
1 Department of Cardiovascular Surgery Shin-Tokyo Hospital Chiba, Japan
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For reprint information contact: Hitoshi Hirose, MD Tel: 81 471 24 6666 Fax: 81 471 24 6764 email: genex{at}nifty.com Department of Cardiovascular Surgery, Kobari General Hospital, 29-1 Yokouchi, Noda City, Chiba 278-8501, Japan.
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Abstract
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Gastric carcinoma was found incidentally while harvesting the gastroepiploic artery in 2 patients undergoing coronary artery bypass grafting. Careful examination of the stomach before harvesting the gastroepiploic artery is mandated, and if any masses are detected, an alternative conduit should be used.
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INTRODUCTION
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Adenocarcinoma of the stomach is the most common malignant tumor and the leading cause of death in Japan. The incidence of gastric cancer in adults aged 40 years or older in the Japanese population was reported to be 0.12%.1 Most cases are asymptomatic and diagnosed by an upper gastrointestinal study or endoscopy. We frequently use the gastroepiploic artery (GEA) in coronary artery bypass grafting (CABG), and found 2 cases of gastric cancer while harvesting this artery.
The GEA was harvested in 1,074 of 2,219 patients (48.4%) undergoing CABG between January 1993 and August 2000. The criteria for using GEA were coronary artery disease with no history of peptic ulcer or previous upper abdominal surgery. The length of the GEA was assessed by preoperative angiography, and its diameter and local atherosclerosis were assessed intraoperatively. A hypo-plastic GEA or a calcified lesion in the GEA excluded its use as a bypass conduit. The harvested GEA was used as an in-situ graft for coronary anastomosis in the distal right coronary artery (RCA) system. The details of GEA harvesting have been published elsewhere.2
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CASE REPORTS
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CASE 1
A 69-year-old man who had a previous myocardial infarction and recent angina pectoris, was admitted for CABG. Coronary angiography revealed restenosis of the previously stented RCA, and marked stenosis of the left anterior descending artery (LAD) and the left circumflex artery (LCX). The GEA had no distortion or displacement and it appeared to be intact. Physical examination of the abdomen revealed no significant findings. CABG was planned with the left internal mammary artery (LIMA) to the LCX, the right internal mammary artery (RIMA) to the LAD, and the GEA to the posterior descending branch of the RCA. During surgery, the GEA had good pulsation and sufficient length for the bypass; however, a firm mass was palpated in the stomach. The initial plan of GEA grafting to the RCA was abandoned and saphenous vein was used as an alternative conduit. The surgery was completed under cardiopulmonary bypass with 5 grafts: LIMA to LAD; a composite graft of the RIMA sequentially to the diagonal artery, the high lateral artery, and the posterolateral branch of the LCX; and saphenous vein to the RCA. Postoperative upper endoscopy and gastro-intestinal studies revealed well-differentiated adeno-carcinoma of the stomach at the posterior wall of the fundus of the stomach. Postoperative recovery was uncomplicated and the patient was discharged after 13 days. He underwent total gastrectomy at a local hospital 2 months after CABG. Advanced stage III-A adeno-carcinoma (T3N1M0) was found in the stomach. Only one lymph node at the lesser curvature was positive for cancer, the others were negative. No cardiac events were reported during the cancer surgery. The patient has been recurrence-free and angina-free for 3.5 years.
CASE 2
An 81-year-old man with a history of previous myocardial infarction and diabetes mellitus developed unstable angina. Cardiac angiography showed complete obstruction of the proximal RCA and severe stenosis of the mid portion of the LAD, as well as moderate mitral regurgitation. Pre-operative angiography of the GEA demonstrated good quality and it appeared to be of sufficient length for revascularization of the RCA. There were no abnormal findings suggesting the presence of a gastric tumor. The patient's abdominal examination was negative and he denied any gastrointestinal symptoms. The initial plan for surgery was mitral valve repair and CABG using LIMA to the LAD, and GEA to the posterior descending branch of the RCA, on cardiopulmonary bypass. During surgery, the patient's upper abdomen was opened by extension of the median sternotomy. The GEA showed a strong pulse and appeared to be of good quality; however, a firm mass was palpated at the lesser curvature of the stomach. Since occult carcinoma of the stomach was suspected, GEA harvesting was aborted, and the RIMA was used as an alternative conduit. The operation was completed using the LIMA to the LAD, and the RIMA to the posterior descending branch of the RCA, off-pump on a beating heart. The mitral valve was not repaired because a transesophageal echocardiogram at the end of CABG had demonstrated only mild regurgitation. Upper endoscopy after CABG revealed advanced adenocarcinoma of the stomach. Otherwise, the patient had an uncomplicated postoperative course and was discharged after the con-firmation of graft patency by postoperative angiography. He was readmitted to our hospital one month after CABG due to upper gastrointestinal bleeding. Subtotal gastrectomy was performed without any cardiac events. Pathology revealed advanced stage III-B (T4N1M0) adenocarcinoma of the stomach. All 4 lymph nodes harvested along the GEA were positive for cancer. The patient has been free from recurrence in the 1.5 years after surgery.
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DISCUSSION
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The GEA has been widely used in CABG with a comparable midterm patency rate to internal mammary artery, and with minimal perioperative risks.3 One of the contraindications for GEA harvesting is upper abdominal malignancy that requires extensive lymph node dissection along the GEA. Hayashi and colleagues4 reported a case of stomach cancer that developed 3 years after CABG using GEA. Because of concern about lymph node metastasis along the GEA, the GEA bypass graft was sacrificed at the time of subtotal gastrectomy and replaced with a saphenous vein graft.
Coronary artery bypass grafting in patients with severe multivessel coronary artery disease and an active malignant tumor has been controversial. Myocardial infarction is the leading cause of death during the perioperative period of cancer surgery in patients who do not undergo coronary revascularization.5 Due to the risk of tumor growth in the period between CABG and cancer surgery, one-stage operations for gastric cancer and CABG have been reported.6 However, incidentally found gastric tumors were not discussed in these papers. It is difficult to perform simultaneous surgery for incidental tumors because the tumor has not yet been diagnosed to be either benign or malignant. The absence of detailed information about the tumor, especially lymph node and distant metastasis, makes concomitant surgery difficult. Both of the patients reported here were negative for occult blood in stools preoperatively, and no abdominal masses were detectable by physical examination. Moreover, preoperative angio-graphy was nondiagnostic in both cases. Thus, it was impossible to diagnose the gastric cancer preoperatively. Only careful examination of the stomach before harvesting the GEA revealed the gastric tumor that was confirmed by upper endoscopy shortly after CABG.
Since lymph node metastasis may occur along the GEA, it should not be used as a conduit if masses are detected in the stomach, and an alternative conduit should be utilized. Cardiopulmonary bypass is known to decrease the patient's immune function and it may increase the chance of tumor dissemination.7,8 Thus, after off-pump CABG was adopted in our institute, patients with severe coronary artery disease and a malignant tumor were designated for off-pump CABG. (In case 1, on-pump CABG was performed because at that time we had no experience of off-pump CABG.) After the completion of coronary revascularization, cardiac risks during gas-trectomy are considered to be as low as in patients who have no coronary artery disease.5 Thus, second-stage surgery can be safely performed.
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REFERENCES
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Hisamichi S. Screening for gastric cancer. World J Surg 1989;13:31–7.[Medline]
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Suma H. Gastroepiploic artery graft: coronary artery bypass graft in patients with diseased ascending aorta — using an aortic no-touch technique. Op Tech Card Thorac Surg 1996;1:185–95.
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Hayashi S, Kawaue Y, Sueshiro M, Kado S, Ono Y. A case of gastric cancer occurred after coronary artery bypass grafting using the right gastroepiploic artery [Japanese]. Nippon Kyobu Geka Gakkai Zasshi 1994;42:105–9.[Medline]
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Foster ED, Davis KB, Carpenter JA, Abele S, Fray D. Risk of noncardiac operation in patients with defined coronary disease: the Coronary Artery Surgery Study (CASS) registry experience. Ann Thorac Surg 1986;41: 42–50.[Abstract]
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Kamiike W, Miyata M, Izukura M, Itoh T, Nezu R, Nakamuro M, et al. Simultaneous surgery for coronary artery disease and gastric cancer. World J Surg 1994; 18:879–82.[Medline]
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Eskola J, Salo M, Viljanen MK, Ruuskanen O. Impaired B lymphocyte function during open-heart surgery. Effect of anaesthesia and surgery. Br J Anaesth 1984;56:333–8.[Abstract/Free Full Text]
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Akchurin RS, Davidov MI, Partigulov SA, Brand JB, Shiriaev AA, Lepilin MG, et al. Cardiopulmonary bypass and cell-saver technique in combined oncologic and cardiovascular surgery. Artif Organs 1997;21:763–5.[Medline]
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H. Hirose, A. Amano, S. Takanashi, and A. Takahashi
Coronary artery bypass grafting using the gastroepiploic artery in 1,000 patients
Ann. Thorac. Surg.,
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1371 - 1379.
[Abstract]
[Full Text]
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Abstract
INTRODUCTION
