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AnnalsofClinicalandMedical
Case Reports
ISSN 2639-8109
Case Report
Advanced Esophagogastric Cancer after Bariatric Procedure
Felix VN1
1
Department of Surgery, University of São Paulo Medical School, Head of the Nucleus of General and Specialized Surgery, São Paulo,
Brazil
2. Key Words:
Bariatric procedure; Gastric bypass;
Roux-en-Y gastrojejunostomy; Gastric
band; Regurgitation; Esophagogastric
cancer
1. Abstract
A 74-year-old man, non-smoker or alcoholic, underwent gastric bypass with stapled division
of the stomach and Roux-en-Y gastrojejunostomy 20 years ago. A band was used to limit the
emptying of the gastric pouch. Follow up was abandoned there are ten years, and, three months
ago, he suddenly began to lose weight again and noticed a large increase in the number of ep-
isodes of regurgitation of food, including liquids. An obstructive undifferentiated cancer was
confirmed by EGD and biopsies. PET-CT proved advanced stage and patient was forwarded to
chemotherapy after a multidisciplinary consensus. Because many of these patients have ongo-
ing regurgitation, surveillance endoscopies seem to be mandatory to avoid too late diagnosis of
associated esophagogastric cancer.
3. Introduction
The safety and efficacy of bariatric operations are well demonstrat-
ed. Gastric bypass is considered the gold standard surgery for the
treatment of morbid obesity, due to its very good long terms re-
sults, with mean loses of 50–70% of excess bodyweight and control
of obesity related diseases, especially if associated to a band to re-
strict the emptying of the small gastricpouch[1-4].
Adenocarcinoma of the esophagus associated to morbid obesity,
also has been highlighted. However, association between weight-
loss operations on the stomach and post-operative esophageal can-
cer must be better studied. We present herein one case of esopha-
geal undifferentiated cancer that occurred longtime after bariatric
procedure and that went unnoticed until reaching advanced stage.
4. Case Report
Written informed consent was obtained for publication of this case
report and accompanying images. A 74-year-old, non-smoker or
alcoholic, morbidly obese man underwent gastric bypass with sta-
pled division of the stomach and Roux-en-Y gastrojejunostomy 20
years ago. A band was used to limit the emptying of the gastric
pouch. A preoperative endoscopic evaluation did not show any
esophagogastric problem and H. Pylori infection was discarded
by biopsies. In the post-operative period, he experienced expected
persistent symptoms of regurgitation, particularly after overeating,
and lost 52 Kg. Two surveillance upper endoscopies discarded any
esophageal, gastric pouch or jejunal disease, except mild esophagi-
tis, until ten years ago, when the follow-up was abandoned.
Three months ago, he suddenly began to lose weight again and no-
ticed a large increase in the number of episodes of regurgitation of
food, including liquids. Body mass index was 16.5, hemoglobin,
8.6 g/dL and serum albumin, 2.7 g/dL.
The passage of the endoscope through the distal esophagus was
made impossible by the presence of an obstructive tumor, and
undifferentiated carcinoma was confirmed by endoscopic biop-
sies submitted to anatomopathological and immunohistochemi-
cal studies. On the contrast-enhanced radiographs, extensive tu-
mor was seen from the distal esophagus (Figure 1), and PET-CT
showed the tumoral mass and several compromised lymph nodes
(Figure 2), in addition to evidence of hepatic metastasis (Figure 3).
Due to the impossibility of endoscopic passage of transtumoral
prosthesis or even of nasoenteric alimentary tube, gastrostomy was
performed in the excluded stomach by videolaparoscopy (Figure
4). The patient was forwarded to chemotherapy after a multidisci-
plinary consensus.
*Corresponding Author (s): Valter Nilton Felix, Department of Surgery, University of São Pau-
lo Medical School, Head of the Nucleus of General and Specialized Surgery, São Paulo, Brazil,
Tele: 55 11 32877456, Fax: 55 11 32832715, E-mail: v.felix@terra.com.br
http://www.acmcasereport.com/
Citation: FelixVN, Advanced EsophagogastricCancerafter BariatricProcedure. AnnalsofClinical
and Medical Case Reports. 2020; 4(1): 1-3.
Volume 4 Issue 1- 2020
Received Date: 12 Apr 2020
Accepted Date: 10 May2020
Published Date: 20 May 2020
Volume 4 Issue 1-2020 Case Report
Figure 1: RX - extensive tumor from the distal esophagus; white arrow: tumor; black arrow:
gastric band
Figure 2: PET-CT – tumoral mass and several compromised lymph nodes
Figure 3 PET-CT – hepatic metastasis
Figure 4: RX – gastrostomy in the excluded stomach
5. Discussion
The association between bariatric procedures and subsequent
development of esophagogastric adenocarcinoma may be coinci-
dental, but this case does at least think about some etiopathogenic
possibilities.
Fobi & Lee [5] and Capella & Capella [6] associated a gastric ring
to Roux-en-Y gastric bypass, restricting the output of food of the
small gastric chamber, in order to enhance efficiency in long-term
weight loss.
The Roux-en-Y reconstruction is considered an effective anti-re-
flux procedure, but the presence of bile in the gastric pouch has
been recognized in obese patient who have had Roux-en-Y gastric
bypass [7]. Besides that, the reflux of gastric acid, secreted within
the gastric pouch, facilitated after the gastric manipulation and an-
atomic modification of the esophagogastric junction, is almost cer-
tainly prolonged, due to the ring [8]. Furthermore, the gastric band
can induce esophageal dysmotility in the long-term follow-up [9],
thus worsening the distal esophagus exposure to refluxate. The
longer contact time of the refluxate with the esophageal mucosa
increases the aggression [10] and the relationship between gas-
troesophageal reflux and the development of Barrett’s metaplasia,
esophageal dysplasia, and adenocarcinoma is well established [11].
The presence of the band may be related to cancer due to impacted
foreign body, which can cause adhesion and local reaction of the
mucosa [12], and increase the internal pressure, acting against the
mucosa, decreasing blood flow, with consequent decrease of pa-
rietal cells number, inducing mucosal metaplastic changes, which
may progress to malignancy [13,14].
In addition, it is also worth thinking that food stasis increases ex-
posure of the lower esophagus to foreign compounds, potential-
ly carcinogenic to the esophageal mucosa as highly suggested in
cancer associated to achalasia [15]. The prolonged contact between
food or other exogenous carcinogens and gastric pouch mucosa
also can be carcinogenic[16].
The association between obesity and adenocarcinoma of the
esophagus and gastric cardia has been highlighted in the literature
for decades [17-19] and it is possible for these obese patients to be
predisposed to cancer prior to bariatric surgery. However, it should
be noted that cancer has arisen many years after the bariatric pro-
cedure [20], as happened in our case, and that new etiopathogenic
factors may be involved.
Because many of these patients have ongoing regurgitation as-
sociated or not with overeating, the recognition of new relevant
symptoms may be difficult and surveillance endoscopies seem to
Copyright ©2020 Felix et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, 2
which permits unrestricted use, distribution, and build upon your work non-commercially.
Volume 4 Issue 1-2020 Case Report
be mandatory at least until prospective studies can adequately clar-
ify whether there is a specific predisposition for some patients to
the onset of cancer. The mere wait for new symptoms may delay the
diagnosis to the point of incurability, as in the reported case.
References
1. Gentileschi P,Kini S, Catarci M. Evidence-based medicine: open and
laparoscopic bariatric surgery. Surg Endosc 2002; 16:736-44.
2. Powell MS, Fernandez AZ Jr. Surgical treatment of morbid obesity:
the laparoscopic Roux-en-Y gastric bypass. Surg Clin N Am 2011;
91: 1203-24.
3. Allen JW, Coleman MG, Fielding GA. Lessons learned from laparo-
scopicgastricbandingformorbidobesity.AmJSurg 2001;182:10-4.
4. Buchwald H. Overview of bariatric surgery. J Am Coll Surg 2002;
194:367–75.
5. FobiM,LeeH, IgweD,FelahyB, JamesE,StanczykM, FobiN.Band
erosion: incidence, etiology, management and outcome after banded
vertical gastric bypass. Obes Surg 2001; 11:699-707.
6. Capella JF,Capella RF.An assessment of vertical banded gastroplas-
ty Roux en Y gastric bypass for the treatment of morbid obesity. Am
J Surg 2002; 183:117-23.
7. Gagne DJ St, Germaine N, Urbandt JE. Laparoscopic revision of
Roux-en-Y gastric bypass for dysphagia and bile reflux. Surg Obes
Relat Dis 2010;6:551–3.
8. Allen JW, Leeman MF, Richardson JD. Esophageal Carcinoma Fol-
lowing Bariatric Procedures. JSLS 2004; 8:372-5.
9. Suter M, Dorta G, Giusti V et al. Gastric banding interferes with
esophageal motility and gastroesophageal reflux. Arch Surg 2005;
140:639-43.
10. Felix VN, Viebig RG. Simultaneous bilimetry and pHmetry in
GERD and Barrett’spatients. Hepatogastroenterol 2005; 52:1452-5.
11. Graham D, Lipman G, Sehgal V et al. Monitoring the premalignant
potential of Barrett’s oesophagus. Frontline Gastroenterol. 2016; 7:
316-22.
12. Negri M, Bendet N, Halevy A et al. Gastric mucosal changes fol-
lowing gastroplasty: a comparative study between vertical banded
gastroplasty and silastic ring vertical gastroplasty. Obes Surg. 1995;
5: 383-6.
13. De Roover A, Detry O, Desaive C, Maweja S, Coimbra C, Honoré P,
et al. Risk of upper gastrointestinal cancer after bariatric operations.
Obes Surg. 2006;16:1656-61.
14. Jain PK, Ray B, Royston CM. Carcinoma in the gastric pouch years
after vertical banded gastroplasty. Obes Surg. 2003; 13:136-7.
15. Klajner S, Yamamuro EM; Felix VN et al. Acalasia e câncer do esô-
fago. In: Felix VN, editor. Gastrão em Notícias. São Paulo: Ed USP
1994; 14: 7-10.
16. Hackert T,Dietz M, Tjaden C et al. Band erosion with gastric cancer.
Obes Surg. 2004; 14:559-61.
17. Lagargren J, Bergstrom R, Nyren O. Association between body mass
and adenocarcinoma of the esophagus and gastric cardia. Ann Intern
Med 1999; 130:883-90.
18. Chow WH, Blot WJ, Vaughan TL ,Risch HA, Gammon MD, Stan-
ford JL, et al. Body mass index and risk of adenocarcinoma of the
esophagus and gastric cardia. J Natl Cancer Inst 1998; 90:150-5.
19. Vaughan TL, Davis S, Kristal A, Thomas DB. Obesity, alcohol, and
tobacco as risk factors for cancers of the esophagus and gastric car-
dia: adenocarcinoma versus squamous cell carcinoma. Cancer Epi-
demiol Biomarkers Prev. 1995;4:85-92.
20. Scozzari G, Trapani R, Toppino M Morino M. Esophagogastric can-
cer after bariatric surgery: systematic review of the literature. Surg
Obes Relat Dis 2013;9:133-42.
http://www.acmcasereport.com/ 3

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Advanced Esophagogastric Cancer after Bariatric Procedure

  • 1. AnnalsofClinicalandMedical Case Reports ISSN 2639-8109 Case Report Advanced Esophagogastric Cancer after Bariatric Procedure Felix VN1 1 Department of Surgery, University of São Paulo Medical School, Head of the Nucleus of General and Specialized Surgery, São Paulo, Brazil 2. Key Words: Bariatric procedure; Gastric bypass; Roux-en-Y gastrojejunostomy; Gastric band; Regurgitation; Esophagogastric cancer 1. Abstract A 74-year-old man, non-smoker or alcoholic, underwent gastric bypass with stapled division of the stomach and Roux-en-Y gastrojejunostomy 20 years ago. A band was used to limit the emptying of the gastric pouch. Follow up was abandoned there are ten years, and, three months ago, he suddenly began to lose weight again and noticed a large increase in the number of ep- isodes of regurgitation of food, including liquids. An obstructive undifferentiated cancer was confirmed by EGD and biopsies. PET-CT proved advanced stage and patient was forwarded to chemotherapy after a multidisciplinary consensus. Because many of these patients have ongo- ing regurgitation, surveillance endoscopies seem to be mandatory to avoid too late diagnosis of associated esophagogastric cancer. 3. Introduction The safety and efficacy of bariatric operations are well demonstrat- ed. Gastric bypass is considered the gold standard surgery for the treatment of morbid obesity, due to its very good long terms re- sults, with mean loses of 50–70% of excess bodyweight and control of obesity related diseases, especially if associated to a band to re- strict the emptying of the small gastricpouch[1-4]. Adenocarcinoma of the esophagus associated to morbid obesity, also has been highlighted. However, association between weight- loss operations on the stomach and post-operative esophageal can- cer must be better studied. We present herein one case of esopha- geal undifferentiated cancer that occurred longtime after bariatric procedure and that went unnoticed until reaching advanced stage. 4. Case Report Written informed consent was obtained for publication of this case report and accompanying images. A 74-year-old, non-smoker or alcoholic, morbidly obese man underwent gastric bypass with sta- pled division of the stomach and Roux-en-Y gastrojejunostomy 20 years ago. A band was used to limit the emptying of the gastric pouch. A preoperative endoscopic evaluation did not show any esophagogastric problem and H. Pylori infection was discarded by biopsies. In the post-operative period, he experienced expected persistent symptoms of regurgitation, particularly after overeating, and lost 52 Kg. Two surveillance upper endoscopies discarded any esophageal, gastric pouch or jejunal disease, except mild esophagi- tis, until ten years ago, when the follow-up was abandoned. Three months ago, he suddenly began to lose weight again and no- ticed a large increase in the number of episodes of regurgitation of food, including liquids. Body mass index was 16.5, hemoglobin, 8.6 g/dL and serum albumin, 2.7 g/dL. The passage of the endoscope through the distal esophagus was made impossible by the presence of an obstructive tumor, and undifferentiated carcinoma was confirmed by endoscopic biop- sies submitted to anatomopathological and immunohistochemi- cal studies. On the contrast-enhanced radiographs, extensive tu- mor was seen from the distal esophagus (Figure 1), and PET-CT showed the tumoral mass and several compromised lymph nodes (Figure 2), in addition to evidence of hepatic metastasis (Figure 3). Due to the impossibility of endoscopic passage of transtumoral prosthesis or even of nasoenteric alimentary tube, gastrostomy was performed in the excluded stomach by videolaparoscopy (Figure 4). The patient was forwarded to chemotherapy after a multidisci- plinary consensus. *Corresponding Author (s): Valter Nilton Felix, Department of Surgery, University of São Pau- lo Medical School, Head of the Nucleus of General and Specialized Surgery, São Paulo, Brazil, Tele: 55 11 32877456, Fax: 55 11 32832715, E-mail: v.felix@terra.com.br http://www.acmcasereport.com/ Citation: FelixVN, Advanced EsophagogastricCancerafter BariatricProcedure. AnnalsofClinical and Medical Case Reports. 2020; 4(1): 1-3. Volume 4 Issue 1- 2020 Received Date: 12 Apr 2020 Accepted Date: 10 May2020 Published Date: 20 May 2020
  • 2. Volume 4 Issue 1-2020 Case Report Figure 1: RX - extensive tumor from the distal esophagus; white arrow: tumor; black arrow: gastric band Figure 2: PET-CT – tumoral mass and several compromised lymph nodes Figure 3 PET-CT – hepatic metastasis Figure 4: RX – gastrostomy in the excluded stomach 5. Discussion The association between bariatric procedures and subsequent development of esophagogastric adenocarcinoma may be coinci- dental, but this case does at least think about some etiopathogenic possibilities. Fobi & Lee [5] and Capella & Capella [6] associated a gastric ring to Roux-en-Y gastric bypass, restricting the output of food of the small gastric chamber, in order to enhance efficiency in long-term weight loss. The Roux-en-Y reconstruction is considered an effective anti-re- flux procedure, but the presence of bile in the gastric pouch has been recognized in obese patient who have had Roux-en-Y gastric bypass [7]. Besides that, the reflux of gastric acid, secreted within the gastric pouch, facilitated after the gastric manipulation and an- atomic modification of the esophagogastric junction, is almost cer- tainly prolonged, due to the ring [8]. Furthermore, the gastric band can induce esophageal dysmotility in the long-term follow-up [9], thus worsening the distal esophagus exposure to refluxate. The longer contact time of the refluxate with the esophageal mucosa increases the aggression [10] and the relationship between gas- troesophageal reflux and the development of Barrett’s metaplasia, esophageal dysplasia, and adenocarcinoma is well established [11]. The presence of the band may be related to cancer due to impacted foreign body, which can cause adhesion and local reaction of the mucosa [12], and increase the internal pressure, acting against the mucosa, decreasing blood flow, with consequent decrease of pa- rietal cells number, inducing mucosal metaplastic changes, which may progress to malignancy [13,14]. In addition, it is also worth thinking that food stasis increases ex- posure of the lower esophagus to foreign compounds, potential- ly carcinogenic to the esophageal mucosa as highly suggested in cancer associated to achalasia [15]. The prolonged contact between food or other exogenous carcinogens and gastric pouch mucosa also can be carcinogenic[16]. The association between obesity and adenocarcinoma of the esophagus and gastric cardia has been highlighted in the literature for decades [17-19] and it is possible for these obese patients to be predisposed to cancer prior to bariatric surgery. However, it should be noted that cancer has arisen many years after the bariatric pro- cedure [20], as happened in our case, and that new etiopathogenic factors may be involved. Because many of these patients have ongoing regurgitation as- sociated or not with overeating, the recognition of new relevant symptoms may be difficult and surveillance endoscopies seem to Copyright ©2020 Felix et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, 2 which permits unrestricted use, distribution, and build upon your work non-commercially.
  • 3. Volume 4 Issue 1-2020 Case Report be mandatory at least until prospective studies can adequately clar- ify whether there is a specific predisposition for some patients to the onset of cancer. The mere wait for new symptoms may delay the diagnosis to the point of incurability, as in the reported case. References 1. Gentileschi P,Kini S, Catarci M. Evidence-based medicine: open and laparoscopic bariatric surgery. Surg Endosc 2002; 16:736-44. 2. Powell MS, Fernandez AZ Jr. Surgical treatment of morbid obesity: the laparoscopic Roux-en-Y gastric bypass. Surg Clin N Am 2011; 91: 1203-24. 3. Allen JW, Coleman MG, Fielding GA. Lessons learned from laparo- scopicgastricbandingformorbidobesity.AmJSurg 2001;182:10-4. 4. Buchwald H. Overview of bariatric surgery. J Am Coll Surg 2002; 194:367–75. 5. FobiM,LeeH, IgweD,FelahyB, JamesE,StanczykM, FobiN.Band erosion: incidence, etiology, management and outcome after banded vertical gastric bypass. Obes Surg 2001; 11:699-707. 6. Capella JF,Capella RF.An assessment of vertical banded gastroplas- ty Roux en Y gastric bypass for the treatment of morbid obesity. Am J Surg 2002; 183:117-23. 7. Gagne DJ St, Germaine N, Urbandt JE. Laparoscopic revision of Roux-en-Y gastric bypass for dysphagia and bile reflux. Surg Obes Relat Dis 2010;6:551–3. 8. Allen JW, Leeman MF, Richardson JD. Esophageal Carcinoma Fol- lowing Bariatric Procedures. JSLS 2004; 8:372-5. 9. Suter M, Dorta G, Giusti V et al. Gastric banding interferes with esophageal motility and gastroesophageal reflux. Arch Surg 2005; 140:639-43. 10. Felix VN, Viebig RG. Simultaneous bilimetry and pHmetry in GERD and Barrett’spatients. Hepatogastroenterol 2005; 52:1452-5. 11. Graham D, Lipman G, Sehgal V et al. Monitoring the premalignant potential of Barrett’s oesophagus. Frontline Gastroenterol. 2016; 7: 316-22. 12. Negri M, Bendet N, Halevy A et al. Gastric mucosal changes fol- lowing gastroplasty: a comparative study between vertical banded gastroplasty and silastic ring vertical gastroplasty. Obes Surg. 1995; 5: 383-6. 13. De Roover A, Detry O, Desaive C, Maweja S, Coimbra C, Honoré P, et al. Risk of upper gastrointestinal cancer after bariatric operations. Obes Surg. 2006;16:1656-61. 14. Jain PK, Ray B, Royston CM. Carcinoma in the gastric pouch years after vertical banded gastroplasty. Obes Surg. 2003; 13:136-7. 15. Klajner S, Yamamuro EM; Felix VN et al. Acalasia e câncer do esô- fago. In: Felix VN, editor. Gastrão em Notícias. São Paulo: Ed USP 1994; 14: 7-10. 16. Hackert T,Dietz M, Tjaden C et al. Band erosion with gastric cancer. Obes Surg. 2004; 14:559-61. 17. Lagargren J, Bergstrom R, Nyren O. Association between body mass and adenocarcinoma of the esophagus and gastric cardia. Ann Intern Med 1999; 130:883-90. 18. Chow WH, Blot WJ, Vaughan TL ,Risch HA, Gammon MD, Stan- ford JL, et al. Body mass index and risk of adenocarcinoma of the esophagus and gastric cardia. J Natl Cancer Inst 1998; 90:150-5. 19. Vaughan TL, Davis S, Kristal A, Thomas DB. Obesity, alcohol, and tobacco as risk factors for cancers of the esophagus and gastric car- dia: adenocarcinoma versus squamous cell carcinoma. Cancer Epi- demiol Biomarkers Prev. 1995;4:85-92. 20. Scozzari G, Trapani R, Toppino M Morino M. Esophagogastric can- cer after bariatric surgery: systematic review of the literature. Surg Obes Relat Dis 2013;9:133-42. http://www.acmcasereport.com/ 3