Carcinoid Tumors and Morbid Obesity

Histopathological Findings in Turkish Patients Undergoing Sleeve Gastrectomy: Is Histopathologic Examination of Sleeve Gastrectomy Specimens Clinically Important?

PURPOSE

Sleeve gastrectomy (SG) is a widely used surgical method in the treatment of obesity. This study aimed to reveal the histopathological changes in SG materials and to investigate the prevalence of clinically important lesions requiring follow-up.

MATERIALS AND METHODS

Three hundred five patients' data who underwent SG were analyzed. Cases were divided into three groups as normal, chronic inactive gastritis (CIG), and chronic active gastritis (CAG). Age, gender, and body mass index (BMI) of the three groups and the differences in the gastritis parameters of CIG and CAG groups were compared.

RESULTS

Thirty-three patients (10.8%) were in the normal group, 145 (47.5%) were in the CIG group, and 127 (41.6%) were in the CAG group. Preoperative endoscopic examination was performed in all cases, but Helicobacter pylori (HP) treatment was not applied. HP were detected in 39.3%, atrophy in 3.9%, intestinal metaplasia (IM) in 4.9%, and lymphoid follicle (LF) in 30% of the cases. Inflammation, atrophy, IM, LF, and HP were significantly higher in the CAG group. The proton pump inhibitor (PPI)-related changes were seen in 20 cases and it was more frequent in the CIG group. Intramucosal signet ring cell carcinoma was detected in 1 case. Endocrine cell hyperplasia and dysplasia were present in 7 cases with CAG. Multiple grade 1 neuroendocrine tumors were detected in just 1 case.

CONCLUSION

In our SG specimens, HP and clinically important lesions were significantly higher in the CAG group. Pathological examination should be carefully done as the lesions detected in SG specimens can change patient management.

Exploring the Relationship between Obesity, Metabolic Syndrome and Neuroendocrine Neoplasms

Obesity is a major burden for modern medicine, with many links to negative health outcomes, including the increased incidence of certain cancer types. Interestingly, some studies have supported the concept of an “Obesity Paradox”, where some cancer patients living with obesity have been shown to have a better prognosis than non-obese patients. Neuroendocrine neoplasms (NENs) are malignancies originating from neuroendocrine cells, in some cases retaining important functional properties with consequences for metabolism and nutritional status. In this review, we summarize the existing evidence demonstrating that obesity is both a risk factor for developing NENs as well as a good prognostic factor. We further identify the limitations of existing studies and further avenues of research that will be necessary to optimize the metabolic and nutritional status of patients living with NENs to ensure improved outcomes.

Inflammation Related to Obesity in the Etiopathogenesis of Gastroenteropancreatic Neuroendocrine Neoplasms

Gastroenteropancreatic neuroendocrine neoplasms (GEP-NENs) are rare neoplasms, which, due to their heterogeneous nature, non-specific symptoms, and lack of specific tumor markers pose many diagnostic and clinical challenges. In recent years, the effectiveness of GEP-NEN diagnosis has increased, which is probably associated with the greater availability of diagnostic tests and the cooperation of many experienced specialists in various scientific disciplines. In addition to the possible genetic etiology, the cause of GEP-NET development is not fully understood. Inflammation and obesity are known risks that contribute to the development of many diseases. Chronic inflammation accompanying obesity affects the hormonal balance and cell proliferation and causes the impairment of the immune system function, leading to neoplastic transformation. This review explores the role of inflammation and obesity in GEP-NETs. The exact mechanisms inducing tumor growth are unknown; however, the profile of inflammatory factors released in the GEP-NET tumor microenvironment is responsible for the progression or inhibition of tumor growth. Both the excess of adipose tissue and the impaired function of the immune system affect not only the initiation of cancer but also reduce the comfort and lifetime of patients.

Esophagogastric Cancer After Sleeve Gastrectomy: A Systematic Review of Case Reports

Introduction

Sleeve gastrectomy (SG) is the most commonly performed bariatric procedure. It has been shown that bariatric surgery reduces cancer risk. However, the risk of esophagogastric cancer after SG has not been defined yet and the development of cancer in the esophagus and stomach remains a matter of concern.

Methods

Web of Science, PubMed and Embase databases were searched. Articles that described the diagnosis and management of esophageal or gastric cancer after SG were considered.

Results

Seventeen esophagogastric cancer patients after SG were included. The age of the patients ranged from 21 to 64 years. Tumors were diagnosed after an interval of 33.9 ±22.8 months from SG (range 4 months–96 months). There were 4 esophageal cancers,4 gastroesophageal cancers and 9 gastric cancers; adenocarcinoma was the most frequent tumor histology (88.2%). The most commonly reported symptoms were food intolerance/dyspepsia (50.0%), vomiting/nausea/regurgitation (35.7%). Upper gastrointestinal endoscopy (UGIE) with biopsy was used for diagnosis in most of the patients. Surgery was performed in 10 patients (58.8%), while 4 patients were treated by endoscopic procedures (23.5%). The mean follow-up length was 12.2 months (range 3 months– 36 months) and the overall disease-free survival rate was 88.9%.

Conclusion

The development of esophagogastric cancer after SG is still not well defined but it may occur at any time. Preoperative and follow-up UGIE are essential in order to allow for prevention, early diagnosis. Further epidemiologic studies are needed to investigate the post-SG-related risk of esophagogastric cancer development.

Duodenal neuroendocrine tumours in morbidly obese: Amalgamated strategy to optimise outcome

The association of gastroenteropancreatic neuroendocrine tumours (GEP-NETs) with obesity has been reported and researched on. Rendering of a laparoscopic treatment treating these concurring pathologies in unison has not been described. Two morbidly obese patients with duodenal NETs underwent a resectional procedure, with curative intent, in the form of laparoscopic subtotal gastrectomy with roux-en-y gastrojejunostomy with partial duodenectomy and a laparoscopic one-anastomosis gastric bypass-mini gastric bypass with remnant gastrectomy and partial duodenectomy. Both patients had an uneventful convalescence with acceptable weight loss and no evidence of tumour recurrence on follow-up. The indolent nature of NETs, as compared to the morbidity of obesity provides the rationale for treating this particular cohort of patients with a surgical procedure that would serve to remove the tumour and also provide therapeutic benefit for obesity. With experience in advanced laparoscopic procedures, this can be accomplished safely with acceptable results.

Gastro-Intestinal Tract Cancers Following Bariatric Surgery: a Narrative Review

The association between obesity and malignancies has been identified epidemiologically. Meanwhile, the increasing global number of bariatric surgeries is reported annually; bariatric surgery's effect on different types of cancers is not well understood. Unfortunately, nonspecific presentations and difficulties regarding investigations make diagnosis challenging. The aim of this study is to compile available data about gastro-intestinal (GI) cancers, occurring after different bariatric surgeries. Although GI cancers are considered a rare complication of obesity surgery, they do exist, and diagnosis needs a high index of suspicion.

Finding carcinoid tumor before bariatric surgery. Is preoperative endoscopy necessary? Case report

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The routine use of upper GI endoscopy in preoperative evaluation of bariatric surgery patients still remains controversial.

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The incidence of cancer increases in obese patients.

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The incidence of gastric neuroendocrine tumors in obese patients is higher than the general population (0.6% to 0.0006%).

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Endoscopic evaluation before bariatric surgery is important in terms of revealing many stomach pathologies that may change the treatment of the patient.

Introduction

Carcinoid tumors are endocrine system-related lesions and 4% of the gastrointestinal tract's neuroendocrine tumors (NET) originate from stomach. In recent years, gastric carcinoid tumors have been reported at increasing rates on endoscopies. In this article, we will present a case of gastric carcinoid tumor detected at the upper gastrointestinal (GI) endoscopy during preoperative bariatric surgery workup.

Case presentation

A 55 years old male patient with body mass index (BMI) 46 kg/m² was scheduled for bariatric surgery. Upper GI endoscopy revealed 2 separate 4–5 mm nodular lesions at gastric corpus and antrum. Biopsies were taken and both lesions were reported as neuroendocrine tumors. It was decided that the Laparoscopic sleeve gastrectomy (LSG) operation would be performed because both lesion areas would remain in the extracted part of stomach.

Discussion

The routine use of upper GI endoscopy in preoperative evaluation of bariatric surgery patients still remains controversial.

Conclusion

Upper GI endoscopy is very important in determining various gastric pathologies and determining the most appropriate surgical method before bariatric surgery.

Gastric carcinoid tumor after laparoscopic gastric banding: Case report of a patient with weight regain

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Although carcinoid accounts for only 1% of all the gastric tumors it is the most common type of neuroendocrine neoplasia of the stomach.

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Its increased incidence among the obese population in relation to the general population.

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Resective gastric bypass may be considered as a treatment of choice for patients who after bariatric surgery were diagnosed with gastric carcinoid and weight regain.

Introduction

Although carcinoid tumours are a rare gastrointestinal neoplasm with an incidence rate of 1–2.5 cases per 100 000 inhabitants, they are the most common neuroendocrine tumour of the stomach.

Presentation of case

A 70-year-old-man consulted for epigastric pain and dyspepsia symptoms. His past medical and surgical history included obesity (BMI: 53.9 kg/m²), hypertension, hyperlipidemia, diabetes mellitus type 2, cardiac failure and a surgical treatment with laparoscopic gastric banding. For the analysis and control of the gastric banding an upper gastrointestinal endoscopy was performed evidencing many small polyps in the gastric antrum, body and fundus. The histopathological examination of the resected specimen revealed a well differentiated carcinoid. Laparoscopic surgery for the removal of the gastric banding and the subtotal gastrectomy leaving a small gastric remnant of approximately 2-cm in size similar to the pouch of a bypass was done. Twelve months after surgery the patient presented a body mass index of 36.6 kg /m².

Discussion

Gastric carcinoid increased incidence among the obese population, although the causing mechanisms are not clear, yet it is likely that metabolic and hormonal effects of the obesity play a role. The resection may be performed either endoscopically when the lesions are small, or surgically according to the tumor type and size.

Conclusion

The resective gastric bypass or gastrectomy with anastomosis by Roux- en- Y bypass may be considered as a treatment of choice for patients who after bariatric surgery were diagnosed with gastric carcinoid and weight regain.

Which is the correlation between carcinoid tumor and Laparoscopic Sleeve Gastrectomy? A case series and literature review

Introduction

Gastric Carcinoid Tumors (GCT) are very rare in general population, but some studies evidenced a higher incidence among bariatric surgery patients. Laparoscopic Sleeve Gastrectomy (LSG) is a widely accepted procedure for the surgical treatment of morbid obesity. LSG acts both in reducing food intake and interfering with hormonal balance in the gut-brain axis. In these patients, incidental GCT diagnosis can occur both during pre-bariatric surgery investigation and during post-operative follow-up.

Methods

We retrospectively analyzed the database of obesity patients submitted to LSG in two different centers to find out incidence of GCT in patients treated by surgery from May 2013 to March 2018.

Results

From the 560 obese consecutive patients underwent LSG, we recorded two cases of patients with GCT (0.36%): the case 1 was a patient who had a pre-operative diagnosis of GTC receiving a curative LSG which totally included the carcinoid in the resected portion; the case 2 was a patient that received a curative endoscopic resection 42 months after LSG.

Discussion

the predisposing factors that can correlate GCT with obesity and LSG and in particular the hormonal changes have been discussed. We illustrated our experience about the management of these tumors in obese patients.

Conclusion

there are neither certain data which evidence a correlation between obesity and GCT, nor data to support the hypothesis of a higher incidence of GCT after bariatric surgery. Based on our experience in obese patients the finding of GCT in the pre-operatory phase is not an absolute contraindication for bariatric surgery.

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Recent observations showed a high incidence of Gastric Carcinoid Tumor (GCT) in candidate patients for bariatric surgery.

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From a multicenter experience with Laparoscopic Sleeve Gastrectomy.

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We retrospectively recorded two GCT cases in obese patients (the first found out during pre-operative investigations and the second one detected 52 months after surgery).

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The possible correlations between obesity, LSG and GTC have been discussed.

Diagnostic Yield and Clinical Implications of Preoperative Upper Gastrointestinal Endoscopy in Morbidly Obese Patients Undergoing Bariatric Surgery

BACKGROUND AND AIMS

Upper gastrointestinal (UGI) endoscopy in patients undergoing bariatric surgery is controversial. It is recommended routinely by some authors to detect benign or malignant pathology that mostly remains asymptomatic. Others recommend selective use, suggesting not much impact on surgical management of detected pathology, especially in asymptomatic patients. The aim of this study was to evaluate the diagnostic yield and impact of pathological findings on routine UGI endoscopy before bariatric surgery in a cohort of morbidly obese Indian patients.

MATERIALS AND METHODS

We retrospectively reviewed preoperative screening UGI endoscopy reports of 283 patients who underwent bariatric surgery from February 2012 to August 2014. Data were collected on clinical information, UGI endoscopic findings, Helicobacter pylori testing, and management.

RESULTS

Ten patients gave a history of gastroesophageal reflux, and the rest had no specific UGI complaints. Fifty-four had no abnormal findings. One hundred ninety-six had a lax lower esophageal hiatus, hiatal hernias of <5 cm, Grade I-II esophagitis, or mild to moderate gastritis or duodenitis that did not have an impact on surgery. Thirty-one had severe erosive gastritis or duodenitis, or polyposis that delayed surgery for treatment and review of biopsies. A large hiatal hernia >5 cm changed surgical plan to Roux-en-Y gastric bypass from a sleeve gastrectomy in 2 cases. None had varices or malignancy.

CONCLUSIONS

Preoperative UGI endoscopy yielded a high proportion of endoscopic abnormalities even in asymptomatic patients. Surgery was delayed to treat severe mucosal lesions and to investigate polypoidal findings in the majority. A change in surgical approach and surveillance for malignancy was needed in a few cases.

Decreased Inpatient Mortality in Obese Patients with Abdominal Nets

BACKGROUND

Neuroendocrine tumors (NETs) of the abdomen are rare tumors with an incidence of 3.56 per 100,000 in the general population. Obesity is a growing public health problem with varying effects on severity of other disease. We investigated the association between obesity and inpatient morbidity/mortality in patients with abdominal neuroendocrine tumors utilizing the Nationwide Inpatient Sample (NIS).

METHODS

We analyzed data from the NIS database to investigate the association between obesity and abdominal NETs using patient information from 22,096 patient-discharges from January 1, 2009 to December 31, 2010.

RESULTS

We demonstrate that obesity is strongly associated with decreased rates of inpatient mortality in patients with NET (OR = 0.6, multivariate P = 0.02) and that malnutrition is associated with nearly 5-fold higher odds of inpatient mortality (multivariate P < 0.0005). We did not find a statistical interaction between obesity and malnutrition; however, patients who were both malnourished and obese had a lower association with mortality risk than purely malnourished patients.

CONCLUSIONS

Our data suggests that nutritional status may be an important factor in inpatient mortality in patients with NETs with obesity being protective.

Gastric carcinoid and obesity: association or coincidence? Report of two cases and literature review

Bariatric surgery is a prevalent procedure due to the high incidence of obesity and comorbidities. Upper gastrointestinal endoscopy is one of the procedures used to evaluate the patient before surgery. However, its role is questionable. The incidental findings during endoscopy are variable including inflammatory diseases, and ulcers, and epithelial and stromal tumors. Herein a report of two obese sisters with incidental gastric carcinoids was diagnosed in prebariatric surgery endoscopy. Case Summary. 35- and 41-year-old female patients presented with obesity and BMI of 102 and 46 kg/m², respectively. Both patients underwent upper gastrointestinal endoscopy as part of presurgical evaluation. Multiple polyps were indentified in both patients, and biopsy was taken. Histological examination revealed tumors that were formed by nests of epithelial cells. The cells have eosinophilic cytoplasm and monomorphic nuclei, typical morphology of neuroendocrine tumors. Conclusions. (1) Upper gastrointestinal endoscopy is an important procedure for prebariatric surgery evaluation. (2) Gastric carcinoid is a rare tumor with higher incidence among obese patients.