Gastric gastrointestinal stromal tumor (GIST) incidentally found and resected during laparoscopic sleeve gastrectomy

Can Incidental Gastric GISTs During Bariatric Surgeries Change the Primary Plan of Surgery? A Single Team Experience and a Systematic Review of Literature

As bariatric surgeries (BS) increase, more incidental findings are liable to be discovered. Incidental gastric gastrointestinal stromal tumors (GISTs) during BS can be found in around 0.7% of the cases. In this article, we have performed a systematic review of the literature and added our data to those of the review to review a conceptual treatment strategy to both improve patient outcomes and decrease the risk of overall cancer. With the rise of new bariatric techniques, we have proposed a new classification to BS to enhance our description of the treatment strategy.

Routine histopathologic examination of the resected specimen after laparoscopic sleeve gastrectomy - what can be expected?

BACKGROUND

Laparoscopic Sleeve Gastrectomy (LSG) is nowadays an established bariatric procedure. Although preoperative gastroscopy is recommended to rule out severe pathologies, there is little evidence about the role of routine histopathologic examination of resected specimens. We sought to identify the prevalence of histopathological relevant findings in patients undergoing LSG and to evaluate their impact in clinical practice.

METHODS

A retrospective analysis on a prospectively collected dataset on patients undergoing LSG between August 2009 and May 2018 in two bariatric centers was performed. Demographic and clinical data and histopathological results were analyzed.

RESULTS

Sixhundred-thrirteen patients were identified, mean age was 43.1 years (14-75), average body mass index was 44.8 kg/m² (34.4-73.9). Histopathology revealed abnormal findings in 47.97% of the patients, most common pathology was chronic non-active or minimally to moderate active gastritis (n = 202;32.95%). Among others, Helicobacter-associated gastritis (n = 33;5.38%), intestinal metaplasia (n = 13;2.12%), micronodular enterochromaffine-like cell hyperplasia (n = 2; 0.33%) and gastrointestinal stromal tumors (n = 6; 0.98%) were present. No malignancies were found. Histopathological results required a change in the postoperative management in 48 patients (7.83%). The costs of histopathological assessment ranged between 0.77% and 2.55% of per-case payment.

CONCLUSION

A wide range of histopathological findings occur in specimens after LSG, requiring a relevant number of patients additional therapies or surveillance. Therefore, routine histopathological examination after LSG is recommendable.

Histologic and Cost-Benefit Analysis of Laparoscopic Sleeve Gastrectomy Specimens Performed for Morbid Obesity

CONTEXT.—

Laparoscopic sleeve gastrectomy (LSG) has quickly become the bariatric surgical procedure of choice for patients with obesity who have failed medical management. Laparoscopic sleeve gastrectomy results in a gastric remnant that is routinely subject to pathologic examination.

OBJECTIVE.—

To perform a histologic and cost-benefit analysis of gastric remnants post-LSG.

DESIGN.—

All LSG cases performed at University Health Network, Toronto, Ontario, Canada, between 2010 and 2019 were reviewed. Specimens that underwent routine histopathologic assessment and ancillary immunohistochemical analysis were analyzed. Baseline patient characteristics and surgical outcomes were obtained from our internal database. The total cost of specimen gross preparation, examination, sampling, and producing and reporting a hematoxylin-eosin slide was calculated.

RESULTS.—

A total of 572 patients underwent LSG during the study period and had their specimens examined histologically. A mean of 4.87 blocks generating 4 hematoxylin-eosin slides was produced. The most common histologic findings reported in LSG specimens ranged from no pathologic abnormalities identified together with proton pump inhibitor-related change. A minority of cases demonstrated clinically actionable histologic findings, of which Helicobacter pylori infection was the most common. The total cost for the complete pathologic analysis of these cases amounted to CaD $66 383.10 (US $47 080.21) with a mean of CaD $116.05 (US $82.40) per case. A total of CaD $62 622.75 (US $44 413.30) was spent on full examination of cases that had no further postoperative clinical impact.

CONCLUSIONS.—

There is a broad spectrum of pathologic findings in LSG specimens, ranging from clinically nonactionable to more clinically actionable. The vast majority of histologic findings had no clinical impact, with only a minority of cases being clinically significant. This study therefore recommends that LSG specimens be subject to gross pathologic examination in the vast majority of cases. However, sections should be submitted for microscopic analysis if grossly evident lesions are present and if there is a clinical/known history of clinically actionable findings.

Primary extra-gastrointestinal stromal tumor (EGIST) of the mesentery: Case report and review of literature

Introduction

Gastrointestinal stromal tumors (GISTs) represent <1% of all gastrointestinal (GI) tumors. Extra-gastrointestinal stromal tumors (EGISTs) are mesenchymal tissue neoplasm arising outside the GI tract. This rare group comprises only 5% of all GISTs. This case demonstrates a rare entity in a patient with non-specific symptoms, a large tumor size and unremarkable past personal and family history.

Presentation of case

We present a 45-year old man with non-specific symptoms who was diagnosed with a primary EGIST arising in the small bowel mesentery after surgery. The tumor was not compromising the GI tract and it was completely resected. The tumor was sent for pathological examination that confirmed the diagnosis. Histological examination revealed a 15 cm in diameter mass, comprised of spindle cells and high mitotic activity. Treatment with imatinib mesylate was initiated.

Discussion

There have been only a few previous reports of EGISTs arising from the small bowel mesentery. It is believed that EGISTs originate from cells with similar pathological characteristics and biological behaviour as the intestinal cells of Cajal. Such tumors are associated with poorer prognosis, lager tumor size and younger presentation than their GI counterparts. The preferred treatment is complete surgical resection. The addition of specific tyrosine kinase inhibitors such as imatinib mesylate is recommended for high risk patients. Even though morphological and immunohistochemical similarities between GISTs and EGISTs are described, their pathogenesis, incidence, genetic background, complications and prognosis are not completely known because they are extremely rare.

Conclusion

EGISTs are very rare tumors which originate from cells outside the GI tract and are associated with a more aggressive biological behavior than their GI counterparts. These tumors may grow without any clinical implications and should be kept in mind in the differential diagnosis for patients presenting with an abdominal mass. Further studies are needed due to lack of large patient cohort studies and long-term follow-up regarding the prognosis and management of this rare pathology.

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EGISTs are extremely rare. They represent only 5% of all GISTs, which comprises only <0.05% of all GI tumors.

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High index of suspicion in patients with nonspecific symptoms and the presence of an abdominal mass is necessary.

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The preferred treatment is a complete surgical resection in low-risk patients.

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Clinicopathologic parameters and clinical implications are not yet described in literature.

Trends in bariatric surgery and incidentalomas at a single institution in Saudi Arabia: a retrospective study and literature review

BACKGROUND

Data are lacking on trends in bariatric surgery and the frequency of incidental findings in Saudi Arabia.

OBJECTIVE

Report on trends in bariatric surgery as well as our experience in incidental findings along with a literature review (mainly on gastrointestinal stromal tumor).

DESIGN

Retrospective chart and literature review.

SETTINGS

Academic tertiary care center.

PATIENTS AND METHODS

We conducted a retrospective study at King Khalid University Hospital and analyzed the data collected from 2009 to 2019. We collected data on age, body mass index (BMI), H pylori infection, type of bariatric surgery performed, and type and location of incidental findings.

MAIN OUTCOME MEASURES

Incidental findings during or after bariatric surgery (in pathology specimen).

SAMPLE SIZE

3052 bariatric surgeries, 46 patients with incidentalomas.

RESULTS

The mean and standard deviation for the age of the 46 patients with incidentalomas was 42.1 (13.9) years and the mean (SD) preoperative BMI was 43.4 (6.4) kg/m². Of 3052 bariatric surgeries performed, the most common type was sleeve gastrectomy (93.9%), followed by gastric bypass surgery (4.58%) and gastric banding (1.47%). The total frequency of incidentalomas was 1.5%; 10.8% of patients had gastrointestinal stromal tumors (GIST), with the stomach being the commonest site for incidental findings. Eighty percent of the patients with GIST were positive for H pylori (P=.01 vs negative patients).

CONCLUSION

The number of incidentalomas and other findings were consistent with other reports. All these findings suggest that bariatric surgeons should take special care before, during, and after a laparoscopic operation in obese patients.

LIMITATIONS

Since this is a single-center, retrospective study, we did not collect data on important variables such as gender, socioeconomic status of the patient, and family history of obesity, and we did not perform a preoperative esophagogastroduodenoscopy.

CONFLICT OF INTEREST

None.

Laparoscopic sleeve gastrectomy performed in a morbidly obese patient with gastrointestinal stromal tumor: a case report and literature review

Background

Gastrointestinal stromal tumor (GIST) is the most frequent submucosal tumor, and with advancements of diagnostic modalities, the incidence of GIST cases diagnosed have increased. Similarly, prevalence of morbid obesity has also rapidly increased over the past decade. Notably, the incidence of GIST in obese patients was reported to be more frequent as compared to the general population. Despite local resection being the first choice for GIST treatment, extensive surgery should also be considered depending on the tumor size and location. Laparoscopic sleeve gastrectomy (LSG), the most popular bariatric procedure, could also be a concomitant treatment option for both morbid obesity and GIST when the tumor is contained within LSG the excision range. There are, however, few reports about LSG planned for GIST preoperatively.

Case presentation

A morbidly obese 46-year-old Japanese male (body weight of 105.4 kg, body mass index (BMI) of 36.6 kg/m²) was diagnosed with an intramural GIST in the gastric fundus. Because of his extreme visceral fat dominated obesity (visceral fat area of 386 cm²), in addition to the size and location of the tumor, we determined that it would be difficult to perform local resection. We planned LSG as a concomitant treatment for both GIST and morbid obesity. After the preoperative examination and 6 months of weight control, the patient lost enough weight to undergo LSG safely. Keeping enough distance away from the tumor, which we observed with an endoscope, we performed LSG to successfully resect the tumor. The patient was discharged uneventfully. Weight loss was successful as his BMI was 21.0 kg/m² at 3 months post-surgery.

Conclusion

We successfully performed LSG in a morbidly obese patient with a large GIST. This is the largest GIST concomitantly resected with LSG reported within current literature.

Review of pathological findings in laparoscopic sleeve gastrectomy specimens performed for morbid obesity

BACKGROUND

Bariatric surgical procedures are employed when there is a failure of lifestyle modification in arresting obesity. Laparoscopic sleeve gastrectomy (LSG) is quickly becoming the bariatric surgical procedure of choice. LSG results in a gastric remnant that is subject to pathological examination. The objective of this paper is to review the literature in regard to histological findings identified in gastric remnants post-LSG and identify the most pertinent histological findings.

MATERIALS AND METHODS

A literature search was performed to identify relevant case series. Data gathered from relevant case series then underwent statistical analysis.

RESULTS

The most common histological findings in an LSG specimen were clinically indolent findings such as no pathological abnormalities identified followed by non-specific gastritis. A minority of cases demonstrated clinically actionable findings for which Helicobacter pylori represented the majority of these findings.

CONCLUSION

There is a broad spectrum of pathological findings in LSG specimens, ranging from clinically indolent to clinically actionable. The most common histological findings are clinically indolent and only a small portion are of clinical significance and, hence, actionable.

Unexpected Intraoperative Findings, Situations, and Complications in Bariatric Surgery

BACKGROUND

Bariatric surgery is considered a safe therapy to treat obesity. Postoperative complications are well known; however, there is a lack of data describing intraoperative complications and/or unexpected findings, and if there is further impact on outcomes.

METHODS

Retrospective study with patients operated between 2013 and 2016 at a single institution. All operative information was collected prospectively and aimed to analyze the incidence and causes of unexpected intraoperative findings, complications, change in surgical plan, extra surgeries, and procedure interruption in patients submitted to bariatric surgery. Secondarily, a morbidity analysis was performed, correlating intraoperative complications with postoperative complications and length of stay.

RESULTS

Four-hundred and five patients were included. Female sex comprised 82% of cases, and a median age of 38 years old was observed; almost 90% were gastric bypass. In 29.3% of cases, there were intraoperative findings, mainly adhesions, abdominal wall hernias, positive methylene blue test, hiatal hernias, and gastrointestinal stromal tumors. Associated surgeries were performed in 8.6% cases, and intraoperative adverse events reported in 7.1%, where organ injury and anastomosis problems were the most frequent. A change in the operative plan was done in 0.9% and surgery interruption in 1.2% of the cases. Early complications were observed in 6.6%. There was no correlation between intraoperative complications and length of stay or early complications.

CONCLUSION

Unexpected intraoperative findings/complications are common in bariatric surgery, but without increasing morbidity or length of stay. Surgery suspension, change in the planned technique, or adding extra (non-bariatric) procedures may occur.

A rare case of incidental finding of GIST during sleeve gastrectomy: Case report

INTRODUCTION

Gastrointestinal stromal tumors (GISTs) is the term used to describe rare stromal neoplasms that are located in the gastrointestinal tract, it most commonly arises in the stomach. GIST is usually asymptomatic and discovered incidentally by Computed Tomography (CT) or Endoscopy.

PRESENTATION OF CASE

We report a case of incidental finding of GIST during Sleeve gastrectomy in a 56 year-old female that presented with a complaint of sever obesity and articular pain in lower limbs. The tumor was not compromising the performance of a save vertical gastric resection, so the resection was done and a mass specimen was sent for pathological examination that confirmed Gist with a low grade of malignancy.

DISCUSSION AND CONCLUSION

As a conclusion, we recommend keeping in mind incidental finding of GIST during abdominal surgeries and especially Sleeve gastrectomy, in order to detect this tumor as earlier as possible and have a good prognosis with a low chance for recurrence.

Histopathology Findings in Patients Undergoing Laparoscopic Sleeve Gastrectomy

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) has gained popularity in the last 10 years for its good results in weight loss and comorbidity control. However, guidelines on the pathological examination of the specimen are lacking. The aim of this retrospective study was to determine the usefulness of the routine specimen examination when presurgery endoscopy (upper gastrointestinal endoscopy, UGIE) and multiple gastric biopsies are part of the preoperative work-up.

METHODS

A retrospective review of records of the patients submitted to LSG between January 2012 and August 2017 was carried out. Sex, age, histopathology findings in the presurgery endoscopy biopsies and surgical specimen, and the prevalence of Helicobacter pylori infection were analyzed.

RESULTS

A total of 925 patients entered the study group (mean age = 44.1 years, Females = 80.3%, BMI = 44.58 kg/m²). The most common histopathology pattern in the endoscopy biopsies and in the surgical specimens was inactive chronic gastritis (64.4 and 55.6%, respectively). Helicobacter pylori infection was 24.6 and 2.48%, respectively. Ninety-nine percent (n 796) of patients with non-significant endoscopy biopsy findings showed the same patterns in specimen analysis. Only three patients (0.3%) who had intestinal presurgery metaplasia were positive in the specimen analysis, and two cases of gastric stromal neoplasms (gastrointestinal stromal tumor and gastric leiomyoma) were found intraoperatively.

CONCLUSION

Most of the findings are non-significant and can be predicted if UGIE plus multiple biopsies is routinely included in the bariatric work-up with significant cost reduction. In those patients who had a significant finding prior to the surgery or intraoperatively, the pathological examination of the specimen is recommended.

Gastric mesenchymal tumors as incidental findings during Roux-en-Y gastric bypass

BACKGROUND

Occurrences of mesenchymal tumors have been more recognized in recent years, and the incidental diagnosis of these lesions during bariatric surgery has been previously reported.

OBJECTIVE

To describe the cases of incidentally diagnosed mesenchymal tumors during consecutive bariatric surgeries.

SETTING

Private health-providing service, Brazil.

METHODS

A retrospective population-based study, which enrolled individuals who consecutively underwent Roux-en-Y gastric bypass at a single center from January 2006 through July 2016.

RESULTS

Of 1502 individuals, there were 16 cases (1.1%) of confirmed mesenchymal tumors. Of these 16 cases, 14 (87.5%) were gastrointestinal stromal tumors and 2 (12.5%) were leiomyomas. The affected individuals were significantly older (aged 46.2 ± 6.3 versus 35.4 ± 7.2 yr; P = .00031), presented a lower body mass index (38.2 ± 5.1 versus 45.3 ± 8.1 kg/m²; P<.00001), and had a lower weight (102.1 ± 17.9 versus 121.1 ± 7.4 kg; P = .00321). None of the individuals presented reported relapses of the mesenchymal tumors.

CONCLUSION

The possibility of incidental gastric mesenchymal tumors during bariatric surgery should not be neglected; a careful inventory of the stomach at the beginning of the procedure and resection of lesions found are mandatory. (Surg Obes Relat Dis 2017;X:XXX-XXX.) © 2017 American Society for Metabolic and Bariatric Surgery. All rights reserved.

Is it necessary to perform full pathologic review of all gastric remnants following sleeve gastrectomy?

BACKGROUND

This study attempts to determine if enough pathological abnormalities in gastric remnants from sleeve gastrectomy exist to warrant full pathologic evaluation in all remnants.

METHODS

Data was collected on patients undergoing sleeve gastrectomy between 08/01/2011 and 06/30/2014. Significant abnormalities were classified as any pathology that might require follow-up or treatment beyond standard follow-up. Age, comorbidities, gender, and Helicobacter pylori titers were analyzed and compared with pathology specimens using 95% confidence intervals and Phi contingency coefficients.

RESULTS

Full pathologic evaluation was available for 351/387 patients (91.2%). No examples of malignancy or dysplasia were identified. Gastritis was the most common abnormality. There was a statistically significant association between preoperative H. pylori and significantly abnormal pathology (p = 0.003). Other comorbidities had no association.

CONCLUSIONS

These results suggest that full pathologic evaluation of the gastric remnant following sleeve gastrectomy is unnecessary, particularly when gross pathology is not noted at initial operation.

Treatment of gastrointestinal stromal tumor (GIST) during bariatric surgery

The gastrointestinal stromal tumor (GIST) is a rare mesenchymal tumor. One should pay special attention when the GIST comes in obese patients during surgery. The laparoscopic resections with standard techniques, such as gastric bypass, have been described with good results. However, GIST resection associated sleeve gastrectomy for the treatment of obesity is rare, but can be done safely, depending on the location of the tumor.

How to approach Incidentally detected Gastrointestinal Stromal Tumor during Laparoscopic Sleeve Gastrectomy: A Report of Two Cases

Laparoscopic sleeve gastrectomy (LSG) is a frequently used bariatric surgery method. It is possible to incidentally detect gastrointestinal stromal tumors (GISTs) of stomach or other gastric tumors during this procedure. In the literature, there is limited data about cooccurrence of GIST in obesity, and treatment of such cases is still controversial. On the contrary, currently accepted treatment of local and nonmetastatic GIST cases is surgery alone, and of cases with systemic disease is surgery combined with imatinib mesylate therapy. Incidental detection of GIST during bariatric surgery may require a modification in the planned procedure, and an extensive exploration and picking a convenient surgical procedure will become necessary. Here, we present two cases – a gastric GIST and a GIST of small intestine – both of which were incidentally detected during LSG performed for obesity.

Spectrum of Gastric Histopathologies in Severely Obese American Patients Undergoing Sleeve Gastrectomy

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is a commonly performed weight loss procedure, but the pathologic findings in sleeve specimens have not been investigated in a US population.

METHODS

We performed a retrospective review of histopathologic findings in LSG specimens from 310 consecutive bariatric patients at the Hershey Medical Center between June 2008 and August 2014.

RESULTS

Patients were 19 to 75 years old (mean 45 years) with a female-to-male ratio of 3:1. The histopathologic findings included the following: no pathological alteration in 214 patients (69.0 %), chronic inactive gastritis in 41 (13.2 %), fundic gland polyp in 17 (5.5 %), proton pump inhibitor therapy effect in 12 (3.9 %), Helicobacter pylori (H. pylori)-associated chronic active gastritis in 10 (3.2 %), chronic active gastritis (H. pylori negative) in 5 (1.6 %), chronic gastritis with intestinal metaplasia in 4 (1.0 %), gastrointestinal stromal tumor (GIST) in 3 (1.0 %), and hyperplastic polyp, granulomatous inflammation, xanthogranulomatous inflammation, and mucosal ulceration in 1 patient each (0.3 %). Prior endoscopy was performed in 8 patients (2.6 %) for unrelated causes, and the results did not change the surgical management. Nine patients (2.9 %) had a concurrent liver biopsy for visual evidence of significant hepatic fibrosis.

CONCLUSION

Although most cases showed no pathologic alteration, a minority had significant findings, with the incidence of GISTs higher than that reported in other series. Despite negative preoperative H. pylori testing, 3.2 % were still histologically positive, raising questions about the accuracy of preoperative methods used for H. pylori testing and treatment. Preoperative endoscopy may not be needed in sleeve patients.

Should We Abandon Routine Microscopic Examination in Bariatric Sleeve Gastrectomy Specimens?

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is a relatively new bariatric surgical procedure to reduce weight in morbidly obese patients, with an overall low rate of complications and thus gaining a worldwide popularity. It provides an opportunity to study the pathology of the stomach in obese patients. Most studies, however, focused on clinical aspects, surgical techniques, and postoperative complications. Few authors studied the histopathologic findings. Whether routine histopathologic examination is warranted in patients with grossly unremarkable LSG specimens and nonsignificant clinical history was not previously studied.

METHODS

We conducted a prospective study over 8 years to compare the prevalence, the morphologic spectrum and importance of histopathologic findings, and the frequency of incidental neoplasms in LSG specimens with other studies. We also proposed a protocol for the gross handling and sectioning of LSG specimens.

RESULTS

We found 546 LSG specimens. Five patients developed iatrogenic postoperative complications, two of which pursued a medicolegal case. There was no association between the histopathologic findings and the complications. Less than 1 % of incidental benign lesions were found. No malignancies were identified. All of the patients without postoperative complications had uneventful outcome after 5 months to 6 years follow-up.

CONCLUSIONS

Routine microscopic examination of all LSG specimens is not necessary. Selective microscopic examination guided by relevant clinical history and macroscopic examination is a better option. This protocol will save money, time, and workload without compromising patient's safety and future management. However, a careful gross description is still necessary in certain cases for potential future medicolegal implications.

Influence of obesity and bariatric surgery on gastric cancer

Esophageal and gastric cancer (GC) are related to obesity and bariatric surgery. Risk factors, such as gastroesophageal reflux and Helicobacter pylori, must be investigated and treated in obese population. After surgery, GC reports are anecdotal and treatment is not standardized. This review aims to discuss GC related to obesity before and after bariatric surgery.

Laparoscopic intragastric surgery and laparoscopic roux-y gastric bypass were performed simultaneously on a morbidly obese patient with a gastric submucosal tumor: a report of a case and review

BACKGROUND

Obesity patients sometimes have gastric submucosal tumors (SMTs). Surgical excision is recommended in cases of SMTs with suspected malignancy or other reasons making follow-up difficult. Laparoscopic intragastric surgery (LIGS) has recently achieved good results in the treatment of gastric SMTs, especially near the esophagogastric junction (EGJ). This procedure has enabled either preservation of the stomach or minimization of the extent of partial resection.

METHODS

The patient is a 43-year-old female with BMI of 48.2 kg/m(2) who is a candidate for LRYGB. A small SMT was found just below the EGJ. A follow-up with an endoscopy would be needed but difficult because the pouch was too small to observe the lesion. We decided to resect the tumor with LIGS and perform LRYGB simultaneously.

RESULTS

We put the trocars as is our usual LRYGB practice. Observing with laparoscopy and endoscopy, three trocars were inserted into the stomach. After marking the margin of the tumor and injecting normal saline to the submucosal layer, resection of the tumor was performed. Suturing of the defects of the mucosa and the holes of the trocars on the stomach was performed. Then, we performed LRYGB as usual. The patient was discharged uneventfully. The pathological findings showed that the tumor was resected completely. Weight loss has succeeded as her BMI is 32.7 at 1 year after the surgery.

CONCLUSIONS

We performed LIGS and LRYGB simultaneously and safely for a morbidly obese patient with a gastric SMT, and our case is the first case of LIGS during a bariatric procedure.

The value of routine gastroscopy before laparoscopic Roux-en-Y gastric bypass surgery in Chinese patients

BACKGROUND

Obesity is closely related to upper gastrointestinal diseases. China has a high incidence of gastropathy. Postoperative examination of the distal stomach becomes extremely difficult after laparoscopic Roux-en-Y gastric bypass surgery (LRYGB). Whether preoperative routine gastroscopy should be performed at all remains controversial. The objective of this study was to explore the value of routine gastroscopy before performing LRYGB in Chinese patients.

METHODS

The preoperative gastroscopy reports of 180 patients who had undergone LRYGB for morbid obesity and/or metabolic syndrome in the Department of Gastrointestinal Surgery of our hospital from January 2009 to August 2013 were retrospectively analyzed.

RESULTS

Gastroscopy showed chronic superficial gastritis (n = 159, 88.3%), reflux esophagitis (n = 19, 10.6%), erosion (n = 69, 38.3%), hiatal hernia (n = 5, 2.8%), gastric ulcer (n = 3, 1.7%), duodenal ulcer (n = 32, 17.8%), and gastric polyps (n = 10, 5.6%).

CONCLUSION

It is useful to perform gastroscopy before LRYGB. The findings of this investigation can help physicians to develop tailored therapies and procedures and thus improve the prognosis considerably. Gastroscopy should be routinely performed in Chinese patients who are planning to undergo bariatric surgery.

Gastric histopathologies in patients undergoing laparoscopic sleeve gastrectomies

BACKGROUND

With 80 % of its population overweight, 47.5 % obese, and having the eighth fattest population worldwide, Kuwait has a serious obesity problem. This has led to widespread practice of bariatric surgery, with little or no studies regarding operative findings and patient follow-up. This study aims to identify the prevalent gastric histopathologies of the patients who have undergone laparoscopic sleeve gastrectomy (LSG) at Amiri Hospital, Kuwait.

METHODS

A retrospective study was done of the gastric pathology specimen results of 656 patients who underwent LSG at Amiri Hospital from 2008 to 2012.

RESULTS

Of the 656 patients, the average age was 33 years, and 480 (73.2 %) were female while 176 (26.8 %) were male. The histopathology results identified 488 (74.4 %) cases with chronic gastritis, 63 (9.6 %) with follicular gastritis, and 12 (1.8 %) with atrophic gastritis. A total of 12 (1.8 %) cases showed findings other than gastritis, including four (0.6 %) cases of gastric polyps, three (0.5 %) cases of granulomatous disease, and one (0.2 %) case each of the following: gastro-intestinal stromal tumor, gastro-intestinal autonomic nerve tumor, intestinal metaplasia, collagenous gastritis, and crypt cell apoptosis. Helicobacter pylori was discovered in 48 (7.3 %) of the patients.

CONCLUSIONS

The majority of gastric histopathology results after LSG in this study had an element of chronic gastritis (74.4 %), which is in keeping with previous studies showing its high prevalence among the obese population. However, a few cases had clinically significant pathologies, and this may alter post-operative management. In view of these results, routine histological examination of the gastric specimens is highly recommended.

Benign, premalignant, and malignant lesions encountered in bariatric surgery

BACKGROUND

Obesity is associated with several comorbidities like diabetes, hypertension, hyperlipidemia, and obstructive sleep apnea. It is also well established that obese patients have an increased risk of several types of cancer like kidney, pancreas, endometrial, breast, and others. The bariatric surgeon needs to be aware of the problem of benign tumors and cancer in obese patients as well as the optimal management of these conditions that may be present at the time of evaluation for bariatric surgery, during the surgical procedure, and in the postoperative period.

DATABASE

A PubMed search for the words "cancer" and "bariatric surgery" and subsequent review of the abstracts identified 40 articles concerning cancerous, benign, and premalignant conditions in bariatric surgery patients. Data were then extracted from full-text articles.

CONCLUSION

Bariatric surgery decreases cancer risk especially in women. RYGB can be an effective treatment for Barrett's esophagus. Patients having esophageal cancer should not undergo bariatric surgery, while those who develop the same postoperatively are usually managed by a combined abdominal and thoracic approach (Ivor Lewis technique). Gastric cancer of the remnant stomach is usually managed by a remnant gastrectomy. A remnant gastrectomy during RYGB would be necessary in conditions that require endoscopic surveillance of the stomach like gastric polyps, intestinal metaplasia, and carcinoid tumors. Sleeve gastrectomy is an excellent option in a patient with GIST or a carcinoid who needs a bariatric operation. Preoperative endoscopy usually does not detect malignant conditions. Postoperative evaluation of the bypassed stomach is possible using various percutaneous and novel endoscopic techniques.

Multiple primary gastrointestinal stromal tumors presenting in jejunum and ileum

Multiple primary gastrointestinal stromal tumors (GIST) are an infrequent finding. Benign and malignant tumors could coexist in the same patient. We discuss one case of a benign jejunal GIST and a malignant ileal GIST coexisting in the same patient and present their radiological characteristics.

Effort, safety, and findings of routine preoperative endoscopic evaluation of morbidly obese patients undergoing bariatric surgery

BACKGROUND

Obesity is becoming an epidemic health problem and is associated with concomitant diseases, such as sleep apnea syndrome and gastroesophageal reflux disease (GERD). There is no standardized diagnostic workup for the upper gastrointestinal tract in obese patients; many patients have no upper gastrointestinal symptoms, and few data are available on safety of endoscopy in morbidly obese patients.

METHODS

Sixty-nine consecutive diagnostic upper gastrointestinal endoscopies in morbidly obese patients (26 men, 43 women; mean age 43.4 +/- 10.9 years) were prospectively evaluated from January to December 2008 in an outpatient setting before bariatric procedures. Sedation was administered with propofol. Data on sedation, critical events, and examination times were recorded, as well as pathological findings.

RESULTS

The patients' mean body mass index was 47.6 +/- 7.9 (range, 35.1-73.3) kg/m(2); 17.4% reported GERD symptoms. The mean duration of the endoscopy procedure (including sedation) was 20.3 +/- 9.3 (range, 5-50) min, and the whole procedure (including preparation and postprocessing) took 58.2 +/- 19 (range, 20-120) min. The mean propofol dosage was 380 +/- 150 (range, 80-900) mg. Two patients had critical events that required bronchoscopic intratracheal O(2) insufflation due to severe hypoxemia (<60% SaO: (2)). Nearly 80% of patients had pathological findings in the upper gastrointestinal tract. Only 20% reported upper gastrointestinal symptoms. Pathologic conditions were found in the esophagus in 23.2% of the patients, in the stomach in 78.2%, and in the duodenum in 11.6%. The prevalence of Helicobacter pylori infection was 8.7%.

CONCLUSIONS

Upper gastrointestinal endoscopy can be performed safely. However, careful monitoring and anesthesiological support are required for patients with concomitant diseases and those receiving sedation. Because 80% of the patients with pathological findings were asymptomatic, every morbidly obese patient should undergo endoscopy before bariatric surgery because there may be findings that might change the surgical strategy.