Ramin Roohipour, MD, Subhash Kini, MD FACS, Daniel Herron, MD FACS. Mount Sinai School of Medicine, New York, N.Y.
Bariatric surgery is becoming increasingly common such that it is now the second most common abdominal procedure in the United States. Estimates suggest that about 220,000 patients underwent bariatric surgery in 2009. On the other hand gastric cancer is the second leading cause of cancer death in the world. The actual incidence of gastric cancer in bariatric population is unknown. As of 2009 there are about 22 case reports of gastric or esophageal cancer in the literature. During the past decade laparoscopic approach has emerged into oncologic surgery for foregut malignancies. However laparoscopic approach in a patient with previous Roux-En-Y gastric bypass is much more complex and technically demanding. This video present a case of gastric adenocarcinoma in a 62 year-old-female who underwent an open gastric bypass 23 years ago. She presented with dysphagia, nausea and vomiting and weight loss. An EGD did not reveal a discrete mass although there was a near obstructing stricture at the level of the gastrojejunostomy. Biopsies showed a moderately differentiated adenocarcinoma. Pre-op work up including CT of the chest, abdomen and pelvis were negative for metastatic disease. Via laparoscopic approach the gastric remnant, gastric pouch and a retrocolic, retrogastric gastrojejunostomy were identified. The gastric remnant and pouch were adherent. After extensive adhesiolysis and proper mobilization the gastric remnant was divided distally. This was followed by division of the distal esophagus and eventually the proximal Roux-limb. These divisions and further mobilization resulted in en bloc resection of the specimen. The reconstruction (esophagojejunostomy) was achieved using EEA. Gross assessment of the specimen showed a diffuse hardening and almost complete obliteration of the gastrojejunostomy site without clear visualization of a mass. The final pathology confirmed invasive moderately differentiated for adenocarcinoma (T3N1Mx). Postoperatively she did well and currently is completing chemoradiation therapy.In conclusion, laparoscopic gastrectomy for gastric cancer is a feasible and safe procedure in patients with previous Roux en Y gastric bypass while achieving resection compared to open approach.
Program Number: V027