Alejandro Garza, MD, Robert Alleyn, MD, Jose Almeda, MD, Ricardo Martinez, MD. UTRGV
Obesity is an epidemic condition worldwide carrying significant morbidity and mortality. Surgical therapy is the only proven effective method to sustain weight loss. Among the different surgical procedures gastric bypass is the most effective. During this surgery, most of the stomach is excluded from the upper gastrointestinal tract which makes future evaluation of the same very challenging. This could potentially lead to delay in diagnosis of any pathology in the bypass stomach. Gastric Cancer is the 14th most common cause of cancer and cause of cancer death in the United States.
We present a case report of a patient who underwent a Roux-en-Y gastric bypass and went on to developed adenocarcinoma in the gastric remnant 28 year after her surgery. She underwent an exploratory laparotomy, extended antrectomy, subtotal gastrectomy including the gastro-colic ligament, and incidental appendectomy. Pathology showed grade 4 undifferentiated adenocarcinoma that penetrated the visceral peritoneum with clear margins. There was angiolymphatic invasion and perineural invasion along with metastatic carcinoma in 5 out of 6 lymph nodes. Patient received adjuvant chemotherapy. The patient continues to be in clinical and radiological remission 3 years after her diagnosis.
There are multiple risk factors for the development of gastric cancer in general. Infection of the gastric mucosa by Helicobacter pylori, which can cause inflammation and result in a pre-malignant lesion. It is one of the most clinically relevant factors because it can be treated before neoplastic changes occurs. Other risk factors include a family history, low fruit and vegetable consumption, obesity, smoking, and previous gastric surgeries.
Due to the surgical anatomic changes, inherent to the Roux N Y Gastric Bypass it is technically difficult to monitor and evaluate the remnant stomach with upper endoscopy which highlights the importance of pre-operative evaluation. There are different non–surgical methods to evaluate the remnant stomach besides any abdominal CT scan. These include radiographic techniques with percutaneous contrast injection, placement of a gastrostomy tube for later access , as well as retrograde endoscopy with a pediatric colonoscope or a double-balloon enteroscope.
According to the literature there are only 8 cases reported of malignancy arising in the remnant stomach after bypass surgery. Due to the low incidence, this case is reported to help physicians carry a high level of clinical suspicion in these patients.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 86696
Program Number: P172
Presentation Session: iPoster Session (Non CME)
Presentation Type: Poster