CASE REPORT

Adenocarcinoma in the jejunal pouch after proximal gastrectomyfor early stage upper gastric cancer: report of a case

Takanori Kurokawa • Motoshi Kanai •

Yukihiro Kaneko • Hiroshi Takahashi •

Toshiji Motohara

Received: 4 April 2011 / Accepted: 6 June 2011 / Published online: 27 January 2012

� Springer 2012

Abstract An 84-year-old male was admitted to a local

clinic suffering from general fatigue with associated ane-

mia, and therefore was referred to our hospital. His medical

history included a proximal gastrectomy with the formation

of a jejunal pouch as a reconstructive treatment for early

upper gastric cancer at 78 years of age (6 years prior).

A type 2 tumor located in the jejunal pouch almost com-

pletely surrounded by small intestinal mucosa was dem-

onstrated by gastrointestinal endoscopy. The biopsy

specimens showed a moderately differentiated tubular

adenocarcinoma. Computed tomography showed no lym-

phadenopathy or hepatic metastases. A resection of the

residual stomach and jejunal pouch was performed. Based

on the histological findings from the resected specimen, the

tumor was considered to be primary adenocarcinoma in the

jejunal pouch. The postoperative course was uneventful,

and the patient has shown no evidence of any recurrence

during the 6-year period after the most recent surgery.

Keywords Jejunal cancer � Jejunal pouch interposition �Gastric cancer � After gastrectomy

Introduction

Recently, jejunal pouch interposition after gastrectomy has

become a common procedure in Japan. Cancer in the

jejunal pouch after gastrectomy is very rare, and only a

small number of cases have been reported [1–4]. All of

these cases were suture line recurrences in the pouch

caused by implantation with exfoliated cancer cells during

the surgery. We were unable to find any reports of primary

cancer in the jejunal pouch after gastrectomy. We herein

report the case of a patient suspected to have primary

adenocarcinoma in the jejunal pouch, which was detected

after proximal gastrectomy for early upper gastric cancer.

Case report

An 84-year-old male was admitted to a local clinic because

of general fatigue. He was suffering from anemia, and was

referred to our hospital in September 2004. He had under-

gone a proximal gastrectomy with jejunal pouch interposi-

tion to treat early upper gastric cancer in June 1998. During

the surgical procedure, the upper one-third of the stomach

was resected using an automatic suturing device (Nakay-

ama suturing instrument), and a jejunal pouch was produced

by means of another automatic suturing device (linear

cutter). Histologically, the tumor was a moderately differ-

entiated tubular adenocarcinoma invading the sub-mucosal

layer, without permeation of the lymphatic or venous cap-

illaries. The proximal and distal margins were free of cancer

cell invasion. No lymph node metastasis was seen

(Stage Ia), and the patient was followed up without adjuvant

chemotherapy. On admission to our hospital in November

2004, hematological studies revealed anemia (hemoglobin

8.3 mg/dl, hematocrit 25.1%). The serum levels of carci-

noembryonic antigen (CEA), and carbohydrate antigen

(CA) 19-9 were within the normal limits (Table 1). Gas-

trointestinal barium radiography showed the esophagus,

jejunal pouch, residual stomach and duodenum; however, it

failed to identify any tumor (Fig. 1a). A type 2 tumor

located in the jejunal pouch was revealed through gastro-

intestinal endoscopy (Fig. 1b). An examination of the

T. Kurokawa (&) � M. Kanai � Y. Kaneko � H. Takahashi �T. Motohara

Department of Surgery, Hakodate Medical Association Hospital,

10-10, Tomioka-cho, Hakodate, Hokkaido 041-8522, Japan

e-mail: t-kurokawa@hakodate-ishikai-hp.jp

123

Surg Today (2012) 42:605–609

DOI 10.1007/s00595-012-0125-9

biopsy specimens showed a moderately differentiated

tubular adenocarcinoma. Computed tomography indicated

no lymphadenopathy or hepatic metastasis. The patient’s

performance status was good. We carried out a resection of

the residual stomach and jejunal pouch. There was no evi-

dence of hepatic or peritoneal recurrence. Reconstruction

was done by a Roux-en Y method. Macroscopically, a

3.0 9 3.0 cm type 2 tumor was evident in the jejunal pouch

(Fig. 2a). Histologically, the lesion was moderately differ-

entiated adenocarcinoma invading the sub-serosal layer

(Fig. 2b). The cancer–stroma relationship was medullary.

Permeation was not observed in either the lymphatic or

venous capillaries. The resected lymph nodes were all

negative for cancer. The postoperative course was

uneventful, and the patient showed no evidence of recur-

rence at the follow-up examination 6 years after the latest

surgery.

Discussion

A number of reconstruction techniques have so far been

devised and attempted to prevent or treat the development

of complications after gastric cancer surgery. Although one

Table 1 The laboratory findings on admission

Normal range Normal range

WBC 5600/ll 4000–9000 Na 138 mEq/l 135-145

RBC 294 9 104/ll 410–530 9 104 K 4.0 mEq/l 3.5–5.0

Hemoglobin 8.3g/dl 13.0–17.0 Cl 107 mEq/l 96–108

Hematocrit 2.5.1% 39.0–52.0 Ca 8.6 mg/dl 8.4–10.0

Platelets 308 9 103/ll 130–400 9 103

Total protein 5.2 g/dl 6.5–8.0 BUN 9 mg/dl 8.0–22.0

Albumin 2.8 g/dl 3.9–5.1 Cr 0.62 mg/dl 0.61–1.04

AST 15 IU/l \35 Glucose 88 mg/dl 70–110

ALT 9 IU/l \32

ALP 254 IU/l 105–340 Tumor marker

LDH 146 IU/l 115–230 CEA 0.6 ng/ml \5.0

Amy 133 U/l 70–220 CA19-9 8 U/ml \37

a bEsophagus

Jejunal pouch

Remnant stomachDuodenum

Fig. 1 a Gastrointestinal barium radiography showed the esophagus, jejunal pouch, residual stomach and duodenum, however, it failed to reveal

any tumor. b Gastrointestinal endoscopy revealed a type 2 tumor located in the jejunal pouch (arrow)

606 Surg Today (2012) 42:605–609

123

of these techniques, jejunal pouch interposition, has been

performed for many years, reports of cancer reoccurring in

the jejunal pouch after gastric cancer surgery are extremely

rare. Only five cases had been reported, as determined by

Medline searches (using the keywords ‘gastric cancer’,

‘recurrence’, and ‘jejunal pouch’) [1–4] (Table 2). These

recurrences developed between the 4th month and 3 years

following the initial surgery, and were typically elevated

tumors or ulcerative lesions that developed on the suture

line in the jejunal pouch or on the esophagojejunal

anastomosis. All of these cases were considered to be

relapses caused by implantation with exfoliated cancer

cells during the surgery.

Suture line recurrence is more frequently encountered in

colorectal cancers [5, 6]. Ryall [7, 8] reported that loose,

viable cancer cells may implant on freshly cut tissues

during surgery in cases of colorectal and breast cancer.

Umpleby [9] reported that exfoliated cells from colorectal

cancer were viable and that large numbers of cancer cells

were shed into the intestinal lumen, implanting on the

a bRemnant stomach Jejunal pouch

Fig. 2 a Surgically resected specimen revealed a type 2 tumor (arrow head) in the jejunal pouch. b Histologically, the lesion was a moderately

differentiated adenocarcinoma invading the subserosal layers (H&E 910)

Table 2 Cases of cancer arising in the jejunal pouch after gastrectomy

No. Author

report year

Age/

gender

Interval to

recurrence

Previous

treatment

Gross

appearance

Therapy Depth of

invasion

Lymph

node

metastasis

Histological

type

Outcome

1 Miyoshi

et al. [1]

74/M 4 months TG, DP, JPI Broad-based

elevated

tumor

Observation Unknown Unknown Well Dead

2 Nishimura

et al. [2]

57/F 3 years PG, JPI Elevated

tumor

RRSJ, RY T3 Positive Poorly Alive

3 Namikawa

et al. [3]

74/M 2 years

9 months

DG, B- II (first

operation) TG,

JPI, RY (second

operation)

Three

elevated

tumors

RRSJ, RY T2a Negative Moderately Alive

4 Shinohara

et al. [4]

60/F 1 year PG, JPI Elevated

tumor

RRSJ, RY T2 Negative Moderately Alive

5 74/M 1 year PG, S-JPI One elevated

tumors, two

ulcerative

lesions

RRSJ, RY T3

T2

Positive Moderately Alive

6 Our case

2010

84/M 6 years PG, JPI Type 2 tumor RRSJ,RY T3 Negative Moderately Alive

TG total gastrectomy, DP distal pancreatectomy, JPI jejunal pouch interposition, DG distal gastrectomy, B-II Billroth II reconstruction,

RY Roux-en Y reconstruction, PG proximal gastrectomy, S-JPI S-shaped jejunal pouch interposition, RRSJ resection of the residual stomach and

jejunal pouch

Surg Today (2012) 42:605–609 607

123

freshly reconstructed anastomosis. However, the exact

mechanism by which this occurs has not yet been

elucidated.

During our investigation, a type 2 tumor was identified in

the jejunal pouch 2 cm to the oral side from the suture line

between the residual stomach and the jejunal pouch. In

addition, although some of the tumors were found close

to the jejuno-jejunal suture line in the pouch, the

mucous membrane of the tumor margins was almost

circumferentially surrounded by small intestinal mucosa

(Fig. 3), and successive transitional areas of cells between

the small intestinal mucosa and tumor were observed

(Fig. 4). Similarly, when gastric cancer surgery had been

performed 6 years previously, then it was diagnosed

as moderately differentiated tubular adenocarcinoma.

However, the gastric cancer remained in the submucosa, and

no metastasis or invasion from the peritoneal side was

observed. Furthermore, no invasion into the lymphatic

Fig. 3 The histopathological

findings of the resected

specimen revealed that the

mucous membrane of the tumor

margins was almost

circumferentially surrounded by

small intestinal mucosa

Cancer cells

Fig. 4 The histopathological

findings revealed successive

transitional areas of cells

between the small intestinal

mucosa and tumor

608 Surg Today (2012) 42:605–609

123

vessels or veins was observed, and the possibility of metas-

tases from the submucosa to the jejunum was considered to

be low.

The frequency of primary small intestine cancer is

0.3–4.9% of all gastrointestinal cancers [10–13]; moreover,

in autopsy cases, the frequency of primary small intestinal

cancer is very low as one-tenth of all metastatic cancer

cases [14]. Even though the precise origin of any tumor

requires some monoclonal evidence from a genetic analy-

sis, the present tumor was considered to be primary jejunal

cancer based on the findings of the above-mentioned his-

topathological examination. The prognosis of small intes-

tine primary adenocarcinoma is poor, with 5-year survival

rates ranging from 20 to 30% [12]. An early and accurate

diagnosis of small intestinal cancer is difficult because of

its rare clinical incidence and lack of specific symptoms

[15]. The favorable prognostic factors for adenocarcinoma

of the small intestine are an absence of nodal metastases

and a well-differentiated tumor grade [12]. The current

patient has remained free from disease after cancer resec-

tion for 6 years without adjuvant chemotherapy. To

improve the nutrition or quality of life after gastric cancer

surgery, the jejunal pouch has been developed, and its

usefulness has been reported [16–19]. Fortunately, the

incidence of cancer developing in the jejunal pouch is very

rare. Nevertheless, follow-ups are required in patients after

gastric reconstruction using a jejunal pouch to check for the

possibility of gastric cancer recurrence or primary adeno-

carcinoma in the pouch.

Conflict of interest Takanori Kurokawa and other co-authors have

no conflicts of interest to declare.

References

1. Miyoshi K, Fuchimoto S, Ohsaki T, Sakata T, Takeda I,

Takahashi K, et al. Suture line recurrence in jejunal pouch

replaced after total gastrectomy for gastric cancer. Gastric Can-

cer. 1999;2:194–7.

2. Nishimura M, Honda I, Watanabe S, Nagata M, Souda H, Miya-

zaki M. Recurrence in jejuna pouch after proximal gastrectomy

for early upper gastric cancer. Gastric Cancer. 2003;6:197–201.

3. Namikawa T, Kobayashi M, Okamoto K, Okabayashi T, Akimori

T, Sugimoto T, et al. Recurrence of gastric cancer in the jejunal

pouch after completion gastrectomy. Gastric Cancer. 2007;10:

256–9.

4. Shinohara T, Kashiwagi H, Nakada K, Nimura H, Ohmura Y,

Yanaga K. Suture line recurrence in the jejuna pouch after

curative proximal gastrectomy for gastric cancer: report of two

cases. Hepatogastroenterology. 2007;54:1902–4.

5. Umpleby HC, Fermor B, Symes MO, Willamson RC. Viability of

exfoliated colorectal carcinoma cells. Br J Surg. 1984;71:659–63.

6. Skipper D, Cooper AJ, Marston JE, Taylor I. Exfoliated cells and

in vitro growth in colorectal cancer. Br J Surg. 1987;74:1049–52.

7. Ryall C. Cancer infection and cancer recurrence. Lancet. 1907;II:

1311–6.

8. Ryall C. The technique of cancer operations, with relation to the

danger of cancer infection. BMJ. 1908;2:1005–8.

9. Umpleby HC, Fermor B, Symes MO, Williamson RCN. Isolation

of viable exfoliated colorectal cancer cells at the site of intestinal

transaction. Br J Surg. 1983;70:680–97.

10. Iiai T, Tani T, Suda T, Okamoto H, Hatakeyama K. Current

standard treatments for small intestinal cancer (in Japanese).

Geka (Surgery). 2001;63:1458–61.

11. Good CA. Tumor of the small intestine. AJR. 1963;89:685–705.

12. Oureil K, Adamus JT. Adenocarcinoma of the small intestine.

Am J Surg. 1984;147:66–71.

13. Hamano K. Small intestinal cancer (in Japanese). Syokakigeka

(Gastroenterological Surgery). 1990;13:953.

14. Harihara Y, Konishi T. Adenocarcinoma of the small intestine (in

Japanese). Geka (Surgery). 2003;65:1412–6.

15. Maekawa H, Sato K, Komatsu Y, Orita H, Sakurada M. Jejunal

cancer detected after a resection of bilateral ovarian metastasis:

report of a case. Surg Today. 2010;40:1084–7.

16. Nakane Y, Okumura S, Akehira K, et al. Jejunal pouch recon-

struction after total gastrectomy for cancer. A randomized con-

trolled trial. Ann Surg. 1995;222:27–35.

17. Zonca P, Maly T, Neoral C, Jacobi CA. Quality of life after

gastrectomy. Rozhl Chir. 2010;89:344–8.

18. Fein M, Fuchs KH, Thalheimer A, Freys SM, Heimbucher J,

Thiede A. Long-term benefits of Roux-en-Y pouch reconstruction

after total gastrectomy: a randomized trial. Ann Surg. 2008;247:

759–65.

19. Lee J, Hur H, Kim W. Improved long-term quality of life in

patients with laparoscopy-assisted distal gastrectomy with jejuna

pouch interposition for early gastric cancer. Ann Surg Oncol.

2010;17:2024–30.

Surg Today (2012) 42:605–609 609

123