Leiomyoma Removed During Laparoscopic Gastric Bypass

Daniel J Mullins, MD, Sean Orenstein, MD, Nissin Nahmias, MD. University of Connecticut

Introduction: Pre-operative upper endoscopy is not uniformly performed prior to Roux-en-Y gastric bypass surgery, the most common weight loss surgery performed worldwide. Current literature has shown that upper endoscopy is important if the patient has symptoms involving potential pathology in the upper intestinal tract. However, data regarding the routine use of upper endoscopy prior to surgery is lacking. It is of utmost importance to routinely perform upper endoscopy to look for abnormal anatomy which may be difficult to assess post-operatively, especially involving the distal stomach and proximal small bowel. Previous studies have shown that abnormal endoscopies may be found in 46% of patients. We report the case of a 54 year old female who was found to have a gastrointestinal stromal tumor during an upper endoscopy prior to her planned laparoscopic roux-en-y gastric bypass.

Methods: A retrospective chart review was performed on a patient who was found to have a mass in the gastric fundus during a pre-operative endoscopy. The entire operative and hospital course was reviewed and presented. An intraoperative video was also recorded reflecting the changes needed to successfully remove the tumor during the gastric bypass procedure. A literature review using PubMed to search MEDLINE searching for articles involving “gastric bypass surgery” and “upper endoscopy” was done and presented as a literature review.
Results: We present the case of a 54 year old female with a pre-operative body mass index of 46 and a history of hypertension, coronary artery disease status post myocardial infarction, gastroesophageal reflux disease, hyperlipidemia, obstructive sleep apnea, ovarian cysts, and degenerative joint disease. The patient had a previous endoscopy prior to referral to a bariatric surgeon which showed 1.2 a mass in the gastric fundus. A mucosal endoscopic biopsy was done and showed no evidence of malignancy. She was referred to a bariatric surgeon for a combined surgical approach that would lead to weight loss to improve her medical problems and for surgical removal of the potential tumor. The bariatric surgeon performed a repeat endoscopy on the day of surgery to localize the tumor with isosulfan blue dye. The procedure was performed in the standard fashion, with the exception of a larger gastric pouch encompassing roughly 70% of the posterior portion of the stomach with definitive visualization by intraoperative endoscopy. The mass was excluded via wedge resection and sequential firings of an endoGIA stapler with blue cartridges. The specimen was removed via an endoscopic retrieval bag. The final pathology was a leiomyoma.

Conclusion: Pre-operative endoscopy should become the standard of care prior to performing gastric bypass surgery in order to identify abnormal pathology which may be missed after surgery. Although rare, benign gastric tumors including leiomyomas and gastrointestinal stromal tumors have the potential for malignant transformation. The laparoscopic approach for removal of both benign and malignant variants of these tumors has already been described in the literature and accepted as a feasible option. Post-operative care will be complicated by the inability to adequately visualize the stomach remnant.
 

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