Distal Gastrectomy and D2 Lymph Node Dissection for Gastric Cancer after Coronary Bypass Grafting Using the Right Gastroepiploic Artery

We present a case of a 74-year-old man who underwent distal gastrectomy for gastric cancer successfully 14 years after coronary artery bypass grafting (CABG) with the right gastroepiploic artery (RGEA). The patient underwent CABG using RGEA at the age of 59. He was well until age of 73 when an early gastric cancer was diagnosed. Esophagogastroduodenoscopy (EGD) revealed a 0-IIc lesion with a diameter of 4 cm at the lesser curvature of the antrum. He underwent endoscopic submucosal dissection (ESD). The resected specimen showed tub2, SM1, UL (–), ly (+), v (–), pHM0 (2 mm) pVM1. Although positive deleterious factors such as ly (+) and pVM1 usually indicated additional surgical resection, he was carefully observed instead, considering the high surgical risk of the resection of RGEA. A year later he was found to have lymph node metastasis around the antrum by abdominal CT. Eventually he underwent distal gastrectomy with D2 lymph node dissection successfully after percutaneous coronary intervention (PCI) to restore coronary blood flow independent from RGEA. RGEA grafts have been used frequently for CABG because of good short and long-term patency. Recently more patients with CABG using RGEA are found to have gastric cancer and require the resection of the RGEA for lymph node dissection as in this case. For safe and successful surgery, it is crucial to restore the coronary flow independent from RGEA with PCI or CABG prior to surgery, and monitor patients carefully with ECG and cardiac function with cooperating anesthesiologists and cardiac surgeons during the surgery.