Curative Resection Following Neoadjuvant Chemotherapy for Advanced Gastric Cancer With Preservation of a Right Gastroepiploic Artery Coronary Artery Bypass Graft: A Case Report

Recently, the right gastroepiploic artery (RGEA) has been used in coronary artery bypass graft (CABG) as an alternative arterial graft. Because of the improvement of prognosis after CABG, malignant diseases are more common in older patients. However, there is a serious problem in patients with gastric cancer after CABG with RGEA graft. In these patients, an interruption of coronary blood supply through the RGEA may cause a life-threatening myocardial ischemia. Therefore, an appropriate strategy is very important to avoid risk while retaining the curability of the operation. We herein describe a 76-year-old Japanese man with advanced gastric cancer who underwent CABG using the RGEA. Abdominal computed tomography (CT) showed #6 lymph nodes (sub-pyloric lymph nodes) metastases surrounding the RGEA. We concluded that curative resection was impossible while preserving the RGEA and started combination chemotherapy using S-1 and cisplatin. After 2 courses of that, #6 lymph nodes were reduced extremely. Thereafter the patient underwent distal gastrectomy with regional lymph node dissection around the RGEA without excision of the RGEA. Histologically, there were no metastases in #6 lymph nodes. Neoadjuvant chemotherapy may be effective for preserving the RGEA graft in a patient with advanced gastric cancer after CABG.Key words: gastric cancer, CABG, RGEA bypass graft, neoadjuvant chemotherapyThe right gastroepiploic artery (RGEA) has been used in coronary artery bypass graft (CABG) surgery.^1,2 It is recognized as a reliable conduit with superior long-term patency.^3–5 The right gastroepiploic artery is mainly targeted to the right coronary artery because of the limitation of its length. According to the report of a Japanese association for coronary artery surgery, CABG was carried out in more than 0.1 million patients over a period of 7 years that ended in 2004, and the RGEA has been used in more than half of these patients.⁶ After CABG for either triple-vessel or left main disease, patients have a 5-year actual survival rate of 92.9% and a cardiac death-free rate of 97.8%.⁷ Long-term survival increases the opportunity for patients to develop malignant diseases. An increased incidence of gastric cancer after CABG with the use of RGEA has been reported.⁶ In these patients, an interruption of coronary blood supply through the RGEA may cause a life-threatening myocardial ischemia. Therefore, an appropriate strategy is required to avoid risk while retaining the curative potential of the operation. We present a case of gastric cancer after CABG with the RGEA in which neoadjuvant chemotherapy led to curative operation while preserving the RGEA.