Case: A 55-year-old male was admitted to the hospital on March 19, 2007, with “epigastric fullness and discomfort for more than 5 months and vomiting after eating for more than half a month”. The patient had undergone a transthoracic proximal gastrectomy + lower esophageal resection + esophageal residual gastric anastomosis 14 years ago for “lower esophageal cancer”. Pre-admission gastroscopy showed: gastric sinus cancer with pyloric obstruction. The patient had normal vital signs, wasted body, moderate to severe malnutrition, and an incision scar of about 25 cm in the seventh intercostal space of the left chest. The patient had a history of chronic hepatitis B for 20 years, and there were signs of cirrhosis in the liver on abdominal ultrasound. After thorough preoperative preparation, a combined transthoracic and abdominal incision was performed under general anesthesia on April 6, 2007. A mass, about 4×3×2 cm3 in size, penetrated the plasma membrane layer and blocked the pyloric duct. Because of more blood leakage during the separation of the adhesions, an intraoperative partial resection of the distal part of the remnant stomach and a Roux-en-Y anastomosis of the remnant stomach and jejunum were performed. The original suprapyloric, subpyloric, lesser curvature, hepatoduodenal ligament lymph nodes and lymph nodes around the right arteriovenous vein of the gastric omentum were cleared, and the main trunk of the right arteriovenous vein of the gastric omentum and the two terminal claw branches innervating the proximal stomach were preserved (see figure below). The postoperative pathological examination showed a low-moderate differentiated adenocarcinoma of the remnant stomach with tumor infiltration of the entire gastric wall and nodule formation on the plasma surface, and lymph node (2/16) metastasis in the cleared lymph nodes. The patient survived at 6 months of follow-up. Discussion: Clinically, for gastric cancer occurring in the substitute esophagus and stomach, total gastrectomy with peripheral lymph node dissection is usually adopted. As the stomach is elevated to the mediastinum after lower esophageal resection, extensive adhesions are easily formed, resulting in a large scope of separation of adhesions, heavy trauma, bleeding, long duration of surgery, heavy blow to the patient, poor postoperative recovery, many complications, and prolonged hospitalization during re-operative resection of the whole stomach [1]. Because most of the tumors in such patients are located in the gastric sinus, for some patients whose tumors are at a relatively early stage or in poor general condition despite local progression, resection of only the distal stomach while preserving the proximal stomach can reduce the scope of surgery, thus reducing intraoperative bleeding, shortening the operative time, and lessening the blow to the patient from surgical trauma, which is an appropriate choice. The vascular supply of the stomach mainly consists of the left gastric artery, the right gastric artery, the left gastroretinal artery, the right gastroretinal artery, the short gastric artery and its accompanying veins. In this patient, during the surgical treatment of lower esophageal cancer, all the vessels except the right artery of the gastric omentum had been severed. It has been reported in the literature that resection of the distal remnant stomach without preserving this vessel can lead to ischemic necrosis of the proximal remnant gastric mucosa [2]. Therefore, if the distal stomach is resected and the proximal stomach is preserved during reoperation, the right artery of the gastric omentum must be preserved to maintain the blood supply to the proximal stomach. In the present case, we performed resection of the distal remnant of the stomach while preserving the proximal remnant, and preserved the main trunk of the right artery of the gastric omentum and its two terminal claw branches that innervate the proximal stomach in order to maintain the blood supply to the proximal remnant. The two cases reported by Motoyama et al. were both patients with gastric cancer after gastric substitution for esophageal cancer, one patient had a highly differentiated adenocarcinoma with tumor invading only the submucosa and was treated with a transabdominal incision to remove the distal stomach and remove the right peripheral lymph nodes of the gastric omentum while preserving the right vessels of the gastric omentum. In the second case, the patient had a hypofractionated adenocarcinoma that infiltrated into the mucosal layer, and the tumor was located at the level of the esophageal fissure, so the distal stomach was resected through a combined thoracoabdominal incision without lymph node removal. In our opinion, distal gastrectomy with preservation of the right vascularity of the gastric omentum is suitable for two types of gastric cancer cases occurring in the substitute esophagus and stomach: firstly, early gastric cancer in which the tumor invades only the mucosa or submucosa, in which the lymph nodes around the right vascularity of the gastric omentum may not be removed because there is no lymph node metastasis in those invading the mucosa; whereas in those infiltrating into the submucosa, lymph node metastasis may occur, so lymph node removal in this area is required. The second category is patients with locally progressive tumor but in poor general condition and not suitable for extensive and prolonged surgery. The patient in this case belongs to this category. The advantages of this procedure are that the scope of surgical separation of adhesions is small, intraoperative bleeding is low, the duration of surgery is short, and the trauma to the patient is light, thus the postoperative recovery is fast, the possible complications are few, and the hospital stay is relatively short; however, it is difficult to separate from the surrounding tissues and preserve the right arterial trunk of the gastric omentum and its terminal branches, which requires patient and careful operation.