In recent years, the incidence of EGJ adenocarcinoma has increased . Gastroesophageal reflux disease, smoking, and obesity are regarded as risk factors for EGJ adenocarcinoma . Surgery is the center of curatively intended treatment of EGJ cancer. However, the optimal surgical strategy for this disease remains controversial . For Siewert type II adenocarcinomas in EGJ cancer, lower esophagectomy and proximal gastrectomy are often performed.
Regarding SAA, the incidence of visceral aneurysms has been reported to be between 0.01 and 2% in the general population . However, in recent years, patients are diagnosed more frequently, despite being nonsymptomatic, due to the advancement of medical imaging equipment. For SAA with diameters exceeding 2 cm, the indication of treatment depends on various factors .
Laparotomy was a common treatment of SAA in the past, but minimally invasive treatment has been increasing nowadays [3, 8]. Moreover, treatment options for SAA include elective splenectomy, aneurysm ligation or resection, and endovascular transcatheter embolization or stent grafting. There are few invasions with endovascular treatment, but SAA in the proximal splenic artery or meandering arteries may not be suitable for endovascular treatment . In the present case, the size of the aneurysm was not a high risk of rupture. If the blood supply to the spleen was inadequate after SAA resection, there was a risk to add unnecessary invasive procedure of splenectomy to the proximal gastrectomy for EGJ cancer. However, because the aneurysm was located slightly proximal to the splenic artery, there was a possibility that endovascular treatment was not enough. There was also a risk of SAA rupture due to postoperative PF. Considering these risks, we could simultaneously perform laparoscopic SAA resection and avoid unnecessary invasive procedures.
A potential problem in this simultaneous surgery is the blood supply to the spleen. In proximal gastrectomy, the short and posterior gastric arteries are divided. They are thought to be collateral circulation pathways when blood supply in the main trunk of the splenic artery is blocked . However, in the present case, we could assess the blood supply to the spleen using fluorescence imaging after proximal gastrectomy (Fig. 3). Unnecessary splenectomy can be avoided when using such a method. In this case, blood supply to the spleen was suspected to be from the great pancreatic artery via the pancreas and from the omental branches of the left gastroepiploic artery via the omental artery (Fig. 4). As a result, there was no appearance of splenic infarction or delayed abscess after the surgery.
To the best of our knowledge, this is the first report of simultaneous surgery for EGJ cancer and SAA in the English literature. Simultaneous surgery has the advantage of reducing invasive procedures to the patient. In laparoscopic proximal gastrectomy with SAA resection, we can avoid concomitant splenectomy if the great pancreatic artery and omental branches from the left gastroepiploic artery can be preserved. Evaluation of blood supply for the spleen using fluorescence imaging is useful for intraoperative decision-making.