COMPLEXITIES IN MANAGING GASTROESOPHAGEAL JUNCTION ADENOCARCINOMA: A CASE REPORT OF TOTAL GASTRECTOMY WITH DISTAL ESOPHAGECTOMY, D2 LYMPHADENECTOMY, AND ROUX-EN-Y ESOPHAGOJEJUNOSTOMY

Abstract

Background: Adenocarcinoma of the gastroesophageal junction (GEJ) poses significant diagnostic and therapeutic challenges due to its complex anatomy and variable treatment approaches between Eastern and Western guidelines. In Indonesia, where resources are limited, the Japanese Gastric Cancer Association (JGCA) guideline is often adapted for surgical management. Case Presentation: We present a 55-year-old man with progressive dysphagia, significant weight loss, and upper gastrointestinal bleeding for four months. Laboratory tests showed elevated tumor markers. Endoscopy revealed a nodular mass at the GEJ extending into the gastric corpus, confirmed by contrast-enhanced abdominal computed tomography (CT). The patient underwent total gastrectomy, distal esophagectomy, and D2 lymphadenectomy in accordance with JGCA guidelines. Reconstruction was performed using Roux-en-Y esophagojejunostomy. Histopathology confirmed a locally advanced, moderately differentiated adenocarcinoma (cT4, N3a). At one month follow-up, the patient reported symptomatic improvement. However, at two months he developed pleural effusion, ascites, and clinical deterioration, and ultimately died from multiple organ dysfunction syndrome (MODS). Conclusion: This case highlights both the technical feasibility and the limitations of radical surgery for advanced GEJ adenocarcinoma. Although total gastrectomy with distal esophagectomy and D2 lymphadenectomy was performed to optimize oncological clearance and symptom control, the outcome underscores the importance of achieving negative margins, integrating multimodal therapy, and addressing the challenges of managing complex upper gastrointestinal cancers in resource-limited settings.