Gastric adenocarcinoma after gastric bypass for morbid obesity: a case report and review of the literature

Gastric cancer after Bariatric Bypass Surgery. Do they relate? (A Systematic Review)

Bariatric bypass surgery has been an effective treatment for morbid obesity. However, there is an increasing number of reported cases of gastric cancer after bypass surgery. Our systematic review showed an increasing trend of gastric cancer cases after bariatric bypass surgery in the last decade, mostly located in the excluded stomach (77%) and diagnosed in an advanced stage. In addition to known risk factors such as tobacco smoking (17%), H. pylori infection (6%), and family history of gastric cancer (3%), bile reflux, a recently proposed cancer-promoting factor, was also estimated in 18% of the cases. Our data suggest that gastric cancer risk assessment should be considered before gastric bypass surgery, and further investigations are needed to determine the value of post-operative gastric cancer surveillance.

Gastric Cancer After Bariatric Surgeries

Bariatric surgery has been covered by medical insurance in Korea, since January 2019; and its number is steadily increasing. Representative bariatric surgeries include adjustable gastric banding, sleeve gastrectomy, and Roux-en-Y gastric bypass. Each surgical method can be applied according to the patient's condition; however, there are other issues to consider in Korea. Because of the high incidence of gastric cancer in Korea, gastroscopy is recommended every two years after the age of 40. Therefore, it is difficult to perform conventional gastroscopy after Roux-en-Y gastric bypass. In this review, the incidence of gastric cancer after representative bariatric surgery was investigated through a literature review, so that it could be used as a reference for the selection of bariatric surgery in Korea.

Gastroesophageal Cancer After Gastric Bypass Surgeries: a Systematic Review and Meta-analysis

Data comparing the occurrence of gastroesophageal cancer after gastric bypass procedures are lacking and are only available in the form of case reports. We perform in this study a systematic review and a meta-analysis of all the reported cases of gastroesophageal cancer following Roux-en-Y gastric bypass (RYGB) and loop gastric bypass-one anastomosis gastric bypass/mini gastric bypass (LGB-OAGB/MGB). We conducted a systematic review of all the reported cases in articles referenced in PubMed/Medline, Cochrane, and Scholar Google. Only cases of gastro-esophageal adenocarcinoma following RYGB or LGB-OAGB/MGB are included. Statistical analysis was done accordingly. Fifty cases were identified, along with 2 reported in this paper. Sixty-one percent (27/44) of the cancers after RYGB were in the gastric tube compared to 37.5% (3/8) after LGB-OAGB/MGB. This resulted in an odds ratio of 0.38 (p-value = 0.26), which failed to prove an increase in cancer occurrence in the gastric tube after LGB-MGB/OAGB compared to RYGB. The most common symptoms were dysphagia for cancers occurring in the gastric tube (15/30) and abdominal pain for those occurring in the excluded stomach (10/22). Twenty-nine/thirty of the cancers in the gastric tube were diagnosed by gastroscopy and 13/22 of the cancers in the excluded stomach were diagnosed by CT scan. Gastroesophageal cancers after gastric bypass procedures occur commonly in the excluded stomach where many are not identified by conventional means. Physician awareness and patient education as well as lifelong follow-up are essential for maintaining bypass surgeries on the beneficial side.

Gastric Pouch Mixed Adenoneuroendocrine Carcinoma With a Mixed Adenocarcinoma Component After Roux-en-Y Gastric Bypass

The Roux-en-Y gastric bypass is one of the most common procedures currently performed for surgical treatment of patients with severe obesity. Gastric cancer after bariatric surgery is not common, with most of them arising in the excluded stomach. Gastric mixed adenoneuroendocrine carcinomas are a rare type of stomach malignancy, composed of both adenocarcinoma and neuroendocrine tumor-cell components, with the latter comprising at least 30% of the whole neoplasm. In this article, we report a unique case of a mixed adenoneuroendocrine carcinoma with a mixed adenocarcinoma (tubular and poorly cohesive) component arising in the gastric pouch of a patient who underwent previous Roux-en-Y gastric bypass for glycemic control. Since stomach cancer is not usual in patients who have formerly undergone bariatric surgery and symptoms tend to be nonspecific, such diagnosis is often rendered at an advanced stage. Full assessment of these patients when presenting such vague symptoms is critical for an early cancer diagnosis.

H. PYLORI INFECTION, ENDOSCOPIC, HISTOLOGICAL ASPECTS AND CELL PROLIFERATION IN THE GASTRIC MUCOSA OF PATIENTS SUBMITTED TO ROUX-EN-Y GASTRIC BYPASS WITH CONTENTION RING: a cross sectional endoscopic and immunohistochemical study

BACKGROUND

Morbid obesity treatment through vertical gastroplasty Roux-en-Y gastric bypass initially used a contention ring. However, this technique may create conditions to the development of potentially malign alterations in the gastric mucosa. Although effective and previously performed in large scale, this technique needs to be better evaluated in long-term studies regarding alterations caused in the gastric mucosa.

OBJECTIVE

To analyze the preoperative and postoperative endoscopic, histological and cell proliferation findings in the gastric antrum and body mucosa of patients submitted to the Roux-en-Y gastric bypass with a contention ring.

METHODS

We retrospectively evaluated all patients submitted to Roux-en-Y gastric bypass with a contention ring with more than 60 months of postoperative follow-up. We compared the preoperative (gastric antrum and body) and postoperative (gastric pouch) gastric mucosa endoscopic findings, cell proliferation index and H. pylori prevalence. We evaluated cell proliferation through Ki-67 antibody immunohistochemical expression.

RESULTS

In the study period, 33 patients were operated with the Roux-en-Y gastric bypass using a contention ring. We found a chronic gastritis rate of 69.7% in the preoperative period (gastric antrum and body) and 84.8% in the postoperative (gastric pouch). H. pylori was present in 18.2% of patients in the preoperative period (gastric antrum and body) and in 57.5% in the postoperative (gastric pouch). Preoperative cell proliferation index was 18.1% in the gastric antrum and 16.2% in the gastric body, and 23.8% in the postoperative gastric pouch. The postoperative cell proliferation index in the gastric pouch was significantly higher (P=0.001) than in the preoperative gastric antrum and body. Higher cell proliferation index and chronic gastritis intensity were significantly associated to H. pylori presence (P=0.001 and P=0.02, respectively).

CONCLUSION

After Roux-en-Y gastric bypass with contention ring, there was a higher chronic gastritis incidence and higher cell proliferation index in the gastric pouch than in the preoperative gastric antrum and body. Mucosa inflammation intensity and cell proliferation index in the postoperative gastric pouch were associated to H. pylori presence and were higher than those found in the preoperative gastric antrum and body mucosa.