De novo gastric adenocarcinoma 1 year after sleeve gastrectomy in a transplant patient

Abstract

Introduction: It has been reported in the literature that upper gastrointestinal malignancies after bariatric surgery are mostly gastro-esophageal, although it is not clear whether bariatric surgery represents a risk factor for the development of esophageal and/or gastric cancer. We report a case of a de novo gastric adenocarcinoma occurring in a transplant patient 1 year after a laparoscopic sleeve gastrectomy.

Presentation of case: A 44 year-old woman with a BMI of 38kg/m(2), hypertension, type 1 diabetes mellitus, multiple malignancies and a pancreas transplant underwent laparoscopic sleeve gastrectomy. The patient presented with intense dysphagias during the follow up. Studies were performed and the diagnoses of grade 2/3 adenocarcinoma were made. The patient underwent a robotic assisted total gastrectomy with a roux-en-y intracorporeal esophagojejunostomy. The procedure resulted in multiple metastasic lymph nodes, focal and transmural invasions to multiple organs with a tumor free margin resection. The patient presented with a postoperative pleural effusion, with no further complications.

Discussion: The diagnosis of gastroesophageal cancer after bariatric surgery is usually late since these patients have common upper gastrointestinal symptoms related to the procedure that could delay the diagnosis. De novo gastric cancer after sleeve gastrectomy has only been reported in one instance, in contrast with other bariatric surgery procedures.

Conclusions: No direct relation has been established between sleeve gastrectomy and the development of gastric cancer. Robotic procedures allow for complex multiorgan resections, while preserving the benefits of minimally invasive surgery.

Keywords: Gastric cancer; Gastric cancer in transplant patient; Novo gastric adenocarcinoma; Robotic gastrectomy; Sleeve gastrectomy.

Fig. 1

Esophagus fluoroscopy identifying gastric stricture (EGJ = Esophago-gastric junction).

Fig. 2

Trocar placement.

Fig. 3

Intraoperative view of the gastric sleeve.

Fig. 4

Intraoperative view of transection at 1st portion of duodenum (A), transverse colon invasion (B), transection of distal pancreas (C) and M-block disection of distal pancreas (D).

Fig. 5

Intraoperative view of mediastinal dissection of distal esophagus (A), transection of distal esophagus (B), jejuno-jejunostomy (C) and esophago-jejunostomy with circular stapler (D).