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Asian J Endosc Surg ISSN 1758-5902

C A S E R E P O RT

Gastric cancer after mini-gastric bypass surgery: A case report and literature review Chun-Chi Wu,1 Wei-Jei Lee,1 Kong-Han Ser,1 Jung-Chien Chen,1 Jun-Juin Tsou,1 Shu-Chun Chen1 & Wai-Sang Kuan2 1 Department of Gastrointestinal and Laparoscopic Bariatric Surgery, Min-Sheng General Hospital, Taoyuan, Taiwan 2 Department of Pathology, Min-Sheng General Hospital, Taoyuan, Taiwan

Keywords Bariatric surgery; gastric cancer; morbid obesity Correspondence Chun-Chi Wu, Department of Gastrointestinal and Laparoscopic Bariatric Surgery, Min-Sheng General Hospital, No. 168, ChingKuo Road, Taoyuan 330, Taiwan. Tel: +886 3317 9599 Fax: +886 3316 4300 Email: [email protected]

Abstract Gastric cancer in the stomach after Roux-en-Y gastric bypass or mini-gastric bypass is rare, but a few cases have been reported since 1991, when the first case emerged. According to the literature, the interval between bypass surgery and the diagnosis of cancer ranged from 1 to 22 years. Given the difficulty of monitoring a bypassed stomach, the potential for gastric cancer must be considered, especially in countries with high incidence of this cancer. The literature reported the first case in the Asia–Pacific region – a woman developed advanced gastric cancer in her stomach 9 years after laparoscopic minigastric bypass for morbid obesity.

Received: 6 April 2013; revised 6 May 2013; accepted 12 May 2013 DOI:10.1111/ases.12052

Introduction Obesity is a condition associated with increased risk of disability, morbidity and early mortality that has already placed a considerable burden on health-care systems worldwide. Bariatric surgery is an effective way for obese individuals to lose weight and gain long-term benefits. However, gastric cancer in the bypassed stomach following gastric bypass surgery and other bariatric operations remains a potential risk (1–7). In this article, we describe a case of gastric cancer arising in the distal bypassed stomach 9 years after laparoscopic mini-gastric bypass (MGB). This is the first such report in the Asia–Pacific region.

Case Presentation A 41-year-old woman underwent laparoscopic MGB in November 2003; she had an initial BMI of 45.4 kg/m2 (body weight 105 kg and height 152 cm). After 2 years, she lost 51.3 kg and her BMI was reduced to 23.2 kg/m2. The patient was not followed up after this period.

However, in January 2013, she suffered from abdominal pain, fullness and tarry stool for a week. On physical examination, there was a bulging mass in the epigastrium that was dull to percussion and mildly tender to palpation. There was no muscle guarding or rebounding tenderness. Laboratory evaluation included a complete blood count and liver function tests, the results of which were normal except for anemia (hemoglobin = 8.0 mg/ dL). Abdominal CT scan showed a large, distended and fluid-filled stomach and wall thickening of the distal antrum, which was causing gastric outlet obstruction (Figure 1). An upper GI series showed smooth passage of contrast medium from the esophagus to the proximal jejunum. These findings led to an exploratory laparotomy. During surgery, the bypassed stomach was large and distended because of outlet obstruction by a pyloric mass (Figure 2). Although the liver was normal, apparent lymphadenopathy and peritoneal seeding were noticed, the suspected cause of which was serosa nodules on the small bowel loops. The distal two-thirds of the bypassed gastric remnant was resected, the duodenal stump was

Asian J Endosc Surg 6 (2013) 303–306 © 2013 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd

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Figure 3 Neoplastic cell with prominent nuclear pleomorphism.

Figure 1 Coronal reformatted CT scan showing concentric tumor (arrow) with contrast enhancement in the gastric antrum.

Figure 2 Specimen showing an ulcerated tumor of the pylorus (arrow).

stapled and lymph node dissection was performed. Then re-anastomosis of the mini-gastric tube and fundus was performed, and a new Billroth II gastrojejunostomy between the proximal gastric remnant and the jejunum was constructed. Pathologic reports showed poorly differentiated adenocarcinoma (Figure 3), pT3N3b(23/25)M1 (peritoneal seeding). The patient had an uneventful postoperative course and was discharged on postoperative day 10. She then completed adjuvant chemotherapy.

Discussion The first report of a gastric bypass procedure was published in 1966 by Mason and Ito. Roux-en-Y gastric

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bypass is currently the most common surgical procedure for morbid obesity (8). In 1997, the MGB procedure was first developed as a modification of the standard Billroth II procedure by Robert Rutledge in the USA. The MGB, which simplified the construction of the standard Billroth II procedure, has been proposed as an alternative procedure to the Roux-en-Y gastric bypass. It is becoming an increasingly popular procedure because of its low risk of complications and good sustained weight loss relative to other bariatric operations (9). Gastric cancer in a bypassed stomach after gastric bypass is rare, but a few cases have been reported worldwide, with the first occurring in 1991 (1). Since then, a total of seven cases have been reported in the English literature, in addition to the present case (Table 1). Among these cases, the intervals between bypass surgery and the diagnosis of cancer ranged from 1 to 22 years. A case diagnosed within 1 year after gastric bypass was suspected of having a pre-existing lesion in the bypassed stomach (6). The most common symptoms and signs, including vague abdominal pain and fullness, were primarily caused by tumor obstruction. Because of a lack of effective tools to monitor the bypassed stomach, most cases were advanced gastric cancer. Most cases occurred in Western countries. The case presented here was the first in the Asia–Pacific region. The paucity of reported cases of gastric cancer in the bypassed stomach suggests it may be an incidental finding. As the number of patients who undergo gastric bypass increases, more cases will likely be reported in the future. Therefore, gastric cancer in the bypassed stomach should be considered a late event, and there should be no increased risk of malignancy in gastric bypass surgery. High-incidence areas for gastric cancer include Eastern Europe, Central and South America, and East Asia,

Asian J Endosc Surg 6 (2013) 303–306 © 2013 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd

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Table 1 Summary of published case reports Study Raijman et al. (1) Lord et al. (2)

Age Sex Bariatric surgery 38

W

71

W

Khitin et al. (3) 57

W

Escalona et al. (4) Corsini et al. (5) Harper et al. (6) Watkins et al. (7) Present case

51

W

Small gastric pouch and loop gastrojejunostomy Open vertical GB (loop gastrojejunostomy) Open transverse stapling of the stomach and loop gastrojejunostomy Open RYGB

57

M

45

BMI pre-BS BMI post-BS† Time from (kg/m2) (kg/m2) BS (years) S/S NR

NR

5

45

45

13

NR

NR

22

41.9

27

8

Open RYGB

NR

NR

4

W

Open vertical-banded RYGB

48

29

1

44

M

Open RYGB

50.6

23.7

18

41

W

Laparoscopic MGB

45.4

23.2

9

Epigastric pain, tarry stool IDA Post-prandial discomfort, gastric outlet obstruction Epigastric pain, gastric outlet obstruction Abdominal pain, weight loss Abdominal pain, distension Abdominal pain, emesis, dehydration Abdominal pain, fullness, tarry stool

Stage ‡

Nation

T4N Mx

USA

T1N0M0

Australia

T4N§M0

USA

T4N3M0

Chile

Unresectable Brazil Unresectable USA T3N0M0

USA

T4N3M1

Taiwan

†Post-BS BMI as recorded on the diagnosis of gastric cancer. ‡Not mentioned. §Positive but not clearly classified. BS, bariatric surgery; GB, gastric bypass; IDA, iron deficiency/anemia; M, man; MGB, mini-gastric bypass; NR, not reported; RYGB, Roux-en-Y gastric bypass; S/S, symptoms and signs; W, woman.

including Taiwan, with a prevalence of 13.85 per 100 000 (10). As the occurrence of gastric cancer remains possible in a bypassed stomach, the potential for gastric cancer must be considered, especially in countries with a high prevalence of gastric cancer. Before bypass, a standard endoscopic evaluation may prove to be the best method for identifying pathologies that require treatment either before or during surgery. However, this method cannot be used postoperatively. This inherent drawback makes evaluation of the bypassed stomach difficult in the long term. To overcome this difficulty, there are several methods that allow for evaluation, including radiographic techniques involving percutaneous contrast injection via the bypassed stomach, placement of a gastrostomy tubes for subsequent access, retrograde endoscopy with a pediatric colonoscope and double-balloon enteroscope (11). However, these procedures either require advanced techniques or invasive procedures; they are not routinely used. In conclusion, it is important to monitor gastric bypass patients presenting with unusual postoperative complaints because gastric cancer is still a possible occurrence in a bypassed stomach. Alternatively, different types of bariatric surgery that do not involve a bypassed stomach and that are also effective for weight loss, such as laparoscopic sleeve gastrectomy with or without duodenojejunal bypass, should be considered.

Acknowledgment The authors have no conflicts of interest or financial ties to disclose.

References 1. Raijman I, Strother SV, Donegan WL. Gastric cancer after gastric bypass for obesity. J Clin Gastroenterol 1991; 13: 191– 194. 2. Lord RV, Edwards PD, Coleman MJ. Gastric cancer in the bypassed segment after operation for morbid obesity. Aust NZ J Surg 1997; 67: 580–582. 3. Khitin L, Roses R, Birkett D. Cancer in the gastric remnant after gastric bypass. Curr Surg 2003; 60: 521–523. 4. Escalona A, Guzmán S, Ibáñez L et al. Gastric cancer after Roux-en-Y gastric bypass. Obes Surg 2005; 15: 423–427. 5. Corsini DA, Simoneti CA, Moreira G et al. Cancer in the excluded stomach 4 years after gastric bypass. Obes Surg 2006; 16: 932–934. 6. Harper JL, Beech D, Tichansky DS et al. Cancer in the bypassed stomach presenting early after gastric bypass. Obes Surg 2007; 17: 1268–1271. 7. Watkins BJ, Blackmun S, Kuehner ME. Gastric adenocarcinoma after Roux-en-Y gastric bypass: Access and evaluation of excluded stomach. Surg Obes Relat Dis 2007; 3: 644–647. 8. Buchwald H & Williams SE. Bariatric surgery worldwide 2003. Obes Surg 2004; 14: 1157–1164.

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9. Lee WJ, Ser KH, Lee YC et al. Laparoscopic Roux-en-Y vs. mini-gastric bypass for the treatment of morbid obesity: A 10-year experience. Obes Surg 2012; 22: 1827–1834. 10. Chiang CC, Chen YC, Chen CJ et al. Cancer trends in Taiwan. Jpn J Clin Oncol 2010; 40: 897–904.

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11. Sakai P, Kuga R, Safatle-Ribeiro AV et al. Is it feasible to reach the bypassed stomach after Roux-en-Y gastric bypass for morbid obesity? The use of the double-balloon enteroscope. Endoscopy 2005; 37: 566–569.

Asian J Endosc Surg 6 (2013) 303–306 © 2013 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd

Gastric cancer after mini-gastric bypass surgery: a case report and literature review.

Gastric cancer in the stomach after Roux-en-Y gastric bypass or mini-gastric bypass is rare, but a few cases have been reported since 1991, when the f...
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